Initial Comments:
A focused fundamental survey was conducted on January 5, 6, 7, and 8, 2021 to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was 36 and the sample consisted of seven individuals. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on staff interview and review of a facility investigation report, it was determined facility staff failed to report an allegation of the use of an unauthorized restrictive intervention and a fracture of unknown origin in a timely manner to facility administration (Individual #1 and #2)
Findings included:
A. Individual #1
1. Review of a facility investigation report revealed an incident regarding the use of an unauthorized restrictive intervention involving this individual had occurred in the facility on May 27, 2020, at 10:10 p.m. The allegation was not reported by staff to facility administration until the next day May 27, 2020, one day after the incident had been observed by staff. The facility investigation determined the allegation regarding the use of an unauthorized restrictive intervention was confirmed.
B. Individual #2
1. Review of a facility investigation report revealed a fall that resulted in a fractured clavicle that had occurred in the facility on August 26, 2020, at 9:00 p.m. The fall was not reported by staff to facility administration until August 29, 2020, four days after the incident had been observed by staff. The facility investigation determined that the fracture was caused by the fall that occurred on August 26, 2020.
B. The Facility Director (FD) was interviewed on January 8, 2021, at 1:30 p.m. During the interview the FD confirmed the above-mentioned findings.
Plan of Correction:0153 Standard Staff Treatment of Clients
The facility failed to ensure that allegations of mistreatment, neglect or abuse were reported in a timely manner in (2) instances that affected Individual #1 and #2.
In the instance of individual #1, was an incident of unauthorized use of restrictive procedure for an individual who was allegedly displaying self induced vomiting.
In the instance of individual #2, was an incident of an unreported fall that resulted in a fractured clavicle. Through investigation of fracture of unknown origin, it was revealed there had been a fall four days prior to the diagnosis of the fracture. The alleged target did not report the fall because the staff did not think there was any injury.
In order to address the deficient areas identified in W0153, the facility will implement the following corrective action and systematic changes to eliminate reoccurrence of the deficient practices noted in W0153:
Individual #1 & #2: Clinical and supervisory staff will in-service all residential staff on the process and protocols in reporting allegations of mistreatment, neglect or abuse of residents. In Individual #1 case, timely reporting of an incident results in timely medical attention and in Individual #2's case, timely reporting results in timely assessment for possible injury and timely modification in a Behavior Support Plan.
The method of corrective action will be an in-service with a written Post-Test on all aspects of abuse and neglect, including timely reporting, timely treatment, and timely modifications in Behavior Support Plans if new inappropriate behaviors are identified by a resident.
The Program Manager and Assistant Supervisors will monitor the corrective action by reviewing the Daily Staff Observation reports on resident shift activity with prompts on "reporting" on issues identified in W0153. The Staff Observation report is signed by the Assistant Supervisor/Senior Staff on Duty.
These corrective actions for Individual #1 and Individual #2 should also be a remedy to address all other individuals who could be adversely affected by the deficient practice identified in W0153.
To measure progress in the Plan of Correction, the Program Manager will provide documentation in the Monthly Incident Management Meetings.
The Program Director, in conjunction with the Program Manager and Unit Manager, will be ultimately responsible for the implementation of the corrective action and systematic change to ensure that the deficient practices do not reoccur.
483.430(e)(3) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
Observations:
Based on staff interview and facility investigation report review, it was determined that facility staff utilized a restrictive intervention that is not an approved behavioral intervention. (Individual #1)
Findings included:
A. Individual #1
1. Review of Individual #1's record on revealed Individual #1 exhibits the behavior of self-induced vomiting (SIV). Individual #1's individual program plan included general supervision during all awake hours, as well as proactive strategies for eliminating the SIV. Restrictive physical interventions were not an integral part of the current individual program plan. (IPP)
2. Review of a facility investigation report revealed that during a "bed check" on May 27, 2020 at 10:10 p.m., the following incident occurred in the bedroom of Individual #1. A staff person entered Individual #1's bedroom and found Individual #1 in her bed with a pillowcase "wrapped around" Individual #1's hands. The staff person immediately removed the pillowcase. The investigation determined that the pillowcase was being used to prevent Individual from engaging in SIV.
3. Review of a facility investigation report further revealed that staff had utilized a restrictive intervention that was not an approved intervention that was included in the IPP. The staff member in question was disciplined and received retraining regarding Individual #1's IPP.
B. The Facility Director (FD) was interviewed on January 8, 2021, at 1:30 p.m. During the interview the FD stated facility staff utilized a restrictive intervention that was not an approved behavioral intervention include the current IPP.
Plan of Correction:W0193 Standard Staff Training Program
The deficiency relates to the facility staff using a restrictive procedure that was not authorized by the Interdisciplinary Team.
Individual #1 was identified as exhibiting self-induced vomiting, and staff response was to use a pillow case like a sleeve for her hands to prevent the behavior. There was no injury, but there was no authorization for this intervention.
The QIDP and Program Specialist will be responsible for conduction a documented team meeting to address Individual #1's behavior of self-induced vomiting. Actions may include establishing a baseline to see if a Behavior Support Plan is indicated. If a Behavior Support Plan (BSP) is indicated, the Interdisciplinary Team will decide on what interventions are effective and necessary to prevent the inappropriate behavior in a safe manner.
In the event that a Behavior Support Plan (BSP) is developed, the QIDP and Program Specialist will ensure that all staff are in-serviced on the Behavioral Support Plan.
The QIDP and Program Specialist, in conjunction with the Interdisciplinary Team will continue to review the needs of all residents with current Behavior Support Plans and those who may need interventions that are not addressed in a plan. This process will continue through direct observation of staff and residents on an ongoing basis, and documented in resident respective monthly progress notes and Quarterly/Annual Reviews. This practice will address not only Individual #1, but all residents who could be adversely affected by the deficient practice.
The Program Manager will document progress in the Plan of Correction for W0193 with documentation of any new Behavior support Plans that have been initiated in a given month, and any modifications in current plans implemented through the QIDP and Program Specialist.
The Program Director, in conjunction with the Program Manager and Unit Manager, will be ultimately responsible for the corrective action to eliminate reoccurrence of deficiencies related to W0193.
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