Initial Comments:
An incident monitoring visit was completed on February 1, 2 and 5, 2024. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was seventy-two, and the sample consisted of eleven individuals.
As a result of this survey, condition level non-compliance was identified for governing body and client protections. A 90-day termination action was recommended effective February 5, 2024.
Plan of Correction:
483.410 CONDITION
GOVERNING BODY AND MANAGEMENT
Name - Component - 00
The facility must ensure that specific governing body and management requirements are met.
Observations:
Based on observations, review of facility documentation, and interview with facility and administrative staff, the governing body of the facility failed to ensure compliance with the condition of client protections.
The Condition was not met as evidenced by:
The governing body of the facility failed to ensure compliance with the condition of participation of client protections. Refer to W 122.
Plan of Correction:Refer to Tag W122
483.410(a)(1) STANDARD
GOVERNING BODY
Name - Component - 00
The governing body must exercise general policy, budget, and operating direction over the facility.
Observations:
Based on observation, record review and interview with administrative staff, the governing body of the facility failed to exercise operation direction over the facility to ensure clients are protected from neglect.
Findings included:
1. The facility failed to develop and implement procedures that prohibit neglect in order to set up a structure to provide goods and services necessary to avoid physical harm for one of one sample Individual who continued to experience multiple serious injuries over a period of thirteen months. This practice is specific to Individual #2. Refer to W 149.
2. The facility failed to have evidence that all alleged violations are thoroughly investigated for two of three sample Individuals final investigations which were reviewed. This practice is specific to Individuals #1, and #11. Refer to W 154.
Plan of Correction:Refer to Tags W149 and W154
483.420(a) CONDITION
CLIENT PROTECTIONS
Name - Component - 00
The facility must ensure the rights of all clients. Therefore the facility must
Observations:
Based on observation, review of facility documents, and interview with facility and administrative staff, the facility failed to ensure condition level compliance in the provision of client protection services.
This Condition is not met as evidenced by:
The facility failed to develop and implement procedures that prohibit neglect in order to set up a structure to provide goods and services necessary to avoid physical harm for one of one sample Individual who continued to experience multiple serious injuries over a period of thirteen months. This practice is specific to Individual #2. Refer to W 149.
Plan of Correction:Refer to Tag W149
483.420(d)(1) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.
Observations:
Based on observations, record review and interview with administrative staff, the facility failed to develop and implement procedures that prohibit neglect in order to provide a structure of goods and services necessary to avoid physical harm for one of one sample Individual who continued to experience multiple serious injuries over a period of thirteen months. This practice is specific to Individual #2.
Findings included:
1. Observations
Observations in the specialized sensory program room were completed on 02/02/2024, from approximately 10:55 AM to 11:05 AM. Individual #2 was observed with his left hand and wrist encased in bandages. He was sitting in his wheelchair which was placed on a wheelchair swing (an apparatus with a flat plate that allows a wheelchair to be placed on it to experience spatial movement); He appeared calm and content. Interview with the staff in the sensory room at approximately 11:00 AM revealed that Individual #2 is blind and needs staff assistance when walking. This staff also stated that if Individual #2 is on enhanced supervision protocol, e.g. 1:1, she will assume the responsibility for that staffing protocol when he is at the sensory program.
Observations were completed in the Apartment 2 residence living room area on 02/05/2024, from approximately 8:40 AM to 8:45 AM, and again at 11:15 AM to 11:20 AM. On both occassions, Individual #1 was observed sitting in a padded wooden chair with a blanket covering his entire body from head to toe. Two male staff were sitting next to Individual #2, one on each side of the chair. When asked during both observations what is Individual #2's staffing ratio, both staff stated, "2:1", "2 staff with Individual #2."
2. Record Review
A review of Individual #2's record was completed on 02/01/2023, from approximately 9:00 AM to 11:50 AM, and on 02/02/2024, from approximately 8:30 to approximately 1:30 PM. This review revealed the following information:
A. Individual Program Plan
A review of a document titled Individual Program Plan (IPP) dated 10/02/2023, noted that Individual #2 is a 61 year old man who currently functions in the profound range of intellectual disabilities. He is also diagnosed as legally blind, generalized anxiety disorder, autistic disorder, pica (eating/craving of things that are not food), microcephaly, cataracts, asthma and dysphagia.
Subsequent review of a document titled, Social Service Evaluation, the report noted the following:
"Individual #2 is a 61-year-old man who is legally blind, ambulatory with two staff person assistance, and uses a wheelchair as needed for transportation by staff. He is non-verbal, and able to follow prompts and cues from staff for direction. Individual #2 may feel around [with his hands] for desired objects and people but is not able to identify body parts. He requires physical assistance for all of his adaptive daily living care. Individual #2 is currently [nothing by mouth] and receives all his hydration and nutrition via a G-Tube. He also wears cloth [incontinence] briefs to mitigate any 'PICA'-related occurrences relative to the plastic content of disposable briefs."
Review of fall assessments completed by the facility nurse, which were associated with the above IPP revealed the following:
9/12/2023
This assesment revealed a score of 12, indicating a moderate risk (Score 6-12) for falls attributed to sensory deficit, specifically hearing and vision and musculoskeletal problems including an altered gait, and altered mental status including deficits in thinking.
01/04/2024
This assessment revealed a score of 13 indicating a high risk for falls (Score 13-20) for musculoskeletal problems including muscle weakness, altered gait and foot problems, and altered mental status including...confusion, memory loss, deficits in thinking, and poor judgement.
B. Behavior Support Plan
A review of documents titled, IDD Behavior Support Plan (BSP) dated 11/17/2022,
and a subsequent plan dated 01/16/2024, revealed identical statements in both documents regarding the staffing ratios necessary for Individual #2. Under the section titled, Supervision Plan, it was noted that staff are to ensure Individual #2 is within field of vision defined as being able to see Individual #2 and positioned in an area where staff can quickly intervene if necessary. These documents further state, "If [Individual #2] requires l:1 supervision or a less restrictive supervision such as 2:1 or 3:1, it will continue until he demonstrates no behavior of concerns for two days and/or as determined by the IDT, based on their analysis of data. Within thirty (30) days of the increased supervision, the IDT must meet to address if continued 1:1 is needed."
The plan outlines the following target behavior concerns;
- self-injurious behaviors, i.e. pulling out tube, or other behaviors with potential to cause harm to himself, including banging his head on hard surfaces;
-physical disruption-dropping to floor,
-taking off clothes at inappropriate times and places;
-non-compliance-swinging arms at or moving away from staff providing care
- pica related behaviors-attempting to or actually ingesting an inedible object including "but (sic) limited to cotton balls, paper, etc."
Further review of the current BSP dated 01/16/2024, under the section titled, updates from Previous Plan, the following statement was documented: "[Individual #2] was placed on 1:1 due to an injury to his finger." No date was identified with that entry.
C. Incident Reports and Interdisciplinary Team meetings
A review of facility incident reports and Interdiscilinary team (IDT) meeting documentation was completed on 02/01/2024, from approximately 9:00 AM to 12:00 PM, 02/02/2024 from approximately 8:30 AM to 1:30 PM, and 02/05/2024 from approximately 8:30 AM to 10:30 AM. These reviews revealed the following:
a. Incident Report 02/28/2023:
Staff reported Individual #2 had an open area on his right knee measuring 1cm x 0.8 cm. Area was cleaned and covered with triple antibiotic ointment and dressing. Currently no sign of infection. Per the supervisor's preliminary findings, Individual #2 is known to crawl on the floor and this type of action may have caused the abrasion to his right knee.
There was no further information on this incident report to indicate that the reason for the injury was examined beyond the fact that Individual #2 is know to crawl on the floor.
b. Incident Report 3/01/2023:
While in the sensory room, Individual #2 was observed with a white object (not defined) in his mouth. Staff placed her hand in his mouth and removed the object. Individual #2's primary care physician (PCP) advised that an on-site chest X-ray be completed with vital signs monitoring twice daily until assessed.
In response to the above incident, the IDT met, and the following actions occurred:
- On 03/01/2023, the IDT met and as a result, Individual #2 was placed on a 1:1 level of supervision for a 30-day period.
- On 3/16/2023, the IDT met and at the time of the meeting, the behavior specialist and the team recommended 1:1 staffing be discontinued due to "no PICA behaviors since being on 1:1" however, the assistant executive director (AED) overrode this decision indicating that 1:1 supervision should continue for 30 days.
- 03/31/2023, the IDT met and at the time of the meeting, the behavior specialist stated Individual #2 has not had any documented pica attempts or occurrences during the last 30 days and behaviors are at baseline level. AED stated that while the investigation was ongoing, Individual #2's 1:1 staffing will continue for another 30 days.
- On 04/18/2023, the facility's administrative review of all materials gathered during the
this investigation confirmed that Individual #2 was discovered with an inedible object in his mouth and also substantiated the confirmation of neglect of care.
c. Incident Report 04/10/2023:
Individual #2 was seen by his Primary Care Physician for edema to his left foot and reluctance to ambulate. He was subsequently transferred to a local emergency room for diagnostic evaluation. At that time, he was diagnosed with a fracture to his left fifth toe.
The facility initiated an investigation for an injury of unknown origin.
- On 04/12/2023, the IDT met and identified that on 04/10/2023, Individual #2 was diagnosed with a fracture of left 5th toe and soft tissue swelling. There was no further actions or recommendations noted by the IDT at this meeting.
- Despite the completion of an investigation with results that confirmed the fracture to the left fifth toe with no cause identified, there was no evidence that the investigation reviewed or considered the level of supervision in place for Individual #2 at the time of this injury, which was 1:1 based on IDT assesment on 03/31/2023.
- A review of an IDT meeting dated 05/08/2023, revealed effective 05/02/2023, Individual #2's 1:1 staffing ratio was discontinued effective 05/08/2023. Going forward, Individual #2 will have a 1:3 staffing ratio. In a subsequent email attachment to these meeting minutes dated 05/10/2023, it is noted that the current staffing protocol for Individual #2, 1:3 staffing, was discontinued and was returned to regular ratio which is a 1:2 staffing ratio.
d. Incident Report 05/18/2023:
A staff person observed bruises on Individual's left and right arm and on his chest. An assesment by a facility nurse described the following: "bruises on bilateral upper arms and right chest. On assessment resident have multiple purple color bruises. On right upper arm one bruise (3 x 2 cm), on left upper arm three bruises top one (1 x 1 cm), middle one (3 x 2 cm), bottom one (8 cm x 2 cm). And on right chest two bruises (3 x2 cm) and (1.5 x 1.5 cm)." Under a section titled, Supervisor's preliminary findings, it was noted that "[Individual #2] known to crawl on the floor, bump into walls and furniture. He will push furniture around in the area without any assistance."
- On 05/22/2023, the IDT met and discussed the incident of bruising on 05/18/2023. At that time, Individual #2 was placed on 1:1 staffing ratio for his safety and protection. The document further states "At a recent Department Head meeting, it was determined that [Individual #2] is appropriate for alternate placement at a different facility as he is no longer as medically involved as his peers. The AED concluded that [Individual #2] will remain on a 1:1 staffing 'ration' until he is transferred to a more appropriate facility. The Nursing Case Manager (NCM) stated she will write the progress order and ensure that a physician's order is written as the 1:1 is for [Individual #2's] medical safety and not for behavioral concerns."
- Further review of this same IDT meeting document, an attached document titled
Eastern Region/IDD Division Case Review-Nursing dated 06/01/2023, noted under the section titled, Med and Treatment Changes the following statement typed in all capital letters; "5/22/2023: 1:1 STAFFING FOR ALL SHIFTS INDEFINITELY." However, further review of this same IDT document revealed other attached documents titled Staff Attendance Sheets for [Individual #2's] Ratio Change dated 06/12/2023. These training sheets state, "[Individual #2] will be placed in regular ratio effective 2nd shift, 06/12/2023."
- The facility initiated an investigation for an injury of unknown origin on 05/19/2023, which was completed on 07/10/2023. This investigation noted the following: "The victim is blind and ambulates. He has been described by numerous staff as often on the go and difficult to manage. The victim has been observed to bump into hard objects such as the wall or pressed against his preferred position which is his wooden recliner. This [Certified Investigator] also notes potential contributing factors to the victim's bruising maybe related to the victim's visual impairment, supervision requirements, and activity level."
On 07/10/2023, this incident was was not confirmed for neglect by the Administrative Review Committee.
e. Incident Report 05/24/2023:
Staff discovered Individual #2 with a small cut on his right arm toward his elbow. Per nursing assessment, it measures 0.8 cm x 0.5 cm skin tear, cleansed and triple antibiotic ointment applied. Further review of this incident report under the section titled Supervisory preliminary findings confirmed the injuries noted to Individual #2. There was no further action listed in this incident report regarding the supervision status for Individual #2 which remained in place since 05/22/2023, i.e. 1:1 staffing protocol.
f. Incident Report 06/24/2023:
Individual #2 was pushing his wooden rocking chair left and right with his hands, removed cushions and began banging his head on his chair. Attempts to redirect initially unsuccessful. Staff asked Individual #2 if he wanted to take a walk and banging ceased. At this time, a small amount of blood was discovered on his forehead. Per nursing assessment, wound measured about 0.7 x 1.2 cm, mild sanguineous (blood) drainage noticed from the site.
g. Incident Report 7/21/2023:
Staff was pushing an Individual in a wheelchair into the living room at which time this staff witnessed Individual #2 attempting to get out of his chair in the living area. Individual #2 turned to his right and got his foot stuck in front of the other, falling with his legs straight, and slamming his head on the heater just above his right ear. His neck was bent, pushing his head into his left shoulder. He rolled onto his back and tried to get up. Staff ran to him but was too late. Another staff came over to sit with him while this staff got the nurse. Nurse completed skin assessment; no unusual marks of injury noted.
- On 07/25/2023, a mini-IDT report revealed a document titled, Eastern Region/IDD Division Case Review-Nursing (no date noted) which states that on 06/23/2023: "[discontinue] 1:1 level of supervision. Resume regular staffing."
h. Incident Report 08/07/2023:
Staff observed Individual #2 had a regular blue plastic diaper on top of a grey cloth diaper. Individual #2 has a diagnosis of pica and should only wear cloth briefs. Nursing assesment information on this report indicates that Individual #2 has a diagnosis of pica and should only wear cloth briefs.
- In a review of a a previous mini-IDT held on 05/26/2023, an addendum to this report notes that "All individuals with a 'PICA' related plans are required to wear cloth briefs." At the time of this incident, Individual #2 had a current behavior plan dated 11/22 which incudes a target behavior of PICA like behaviors.
i. Incident Report 08/09/2023:
Nurse observed Individual #2 intermittently refusing to bear weight, guarding his left foot. Noted redness on top of head, quarter sized open area on left knee. Individual #2 was subsequently diagnosed with chip fracture middle left foot.
- On 08/10/2023, a mini-IDT referred to an incident report dated 08/09/2023, in which Individual #2 was noted to have a left foot fracture middle cuneiform (arch area) and noted that an investigation would be conducted. This mini-IDT states, "Effective 08/09/2023,
[Individual #2] is on a 1:1 staffing ratio pending the outcome of the investigation."
It was further reported that during a follow up appointment with the orthopedist on 08/14/2023, Individual #2 exhibited poor safety awareness and impulsivity during the ride to the doctor's office. Individual #2 was not compliant keeping his seatbelt on and attempted to stand in moving vehicle, leaned forward in his wheelchair, and rocked, and reached towards door/windows. Team met on 08/18/2023, to discuss Individual #2's behaviors and injury. Physical Therapy consult was requested to trial him without wheelchair. "Team adjourned with no follow up required."
- On 08/18/2023, a mini-IDT was held. This document revealed [Individual #2] will remain on 1:1 staffing pending outcome of investigation. Continued review of this document noted that [Individual #2] was on the van for a follow-up orthopedic appointment "with a familiar staff, but the van was pulled over on multiple occasions as [Individual #2] was attempting to grab the driver and would not remain still in his wheelchair. This document noted that due to the 08/14/2023, incident on the van, Individual #2 will have two staff persons assist him on the van plus the driver, and will be assessed by physical therapy as to his ability to sit on a van seat verse sitting in his wheelchair since "he does not want to be in his wheelchair."
- An investigation regarding this foot injury was completed on 09/18/2023. A review of the Administrative Review Committee comments included with this investigation report indicated that based on the information contained within the investigation, this committee was unable to determine what may have occurred as there were no witnesses, and no definitive cause of the injury.
j. Incident Report 08/15/2023:
While staff was repositioning Individual #2, he stood up and lost his balance landing on his elbow causing it to bleed. When staff picked him up, noticed his pant leg was under his foot.
- On 08/18/2023, a mini was held. too review the above the incident. It was noted that Individual #2's pants did not fit him and reminded staff that Individual #2 is to wear pants that fit him and have elastic around the ankles. This report also reiterated Individual #2 is on 1:1 staffing at the time of the fall.
k. Incident Report 09/04/2023:
At 1:52 AM, Individual #2 was in the living room crawling around on the floor when he started to bang his head on the floor. Staff observed a 1.4 x 0.1 cm injury on his head. Nursing assesment documentation on this report noted that neuro checks were instituted. A documentation of follow-up completed by the supervisor noted that "when coverin [Individual #2] 1:1 continue monitor very close."
- There was no further indication that the IDT had examined the use of 1:1 staffing protocol by staff that was utilized at the time of this incident.
l. Incident Report 09/22/2023:
At approximately 12:30 AM, staff noticed a cut on Individual #2's forehead measuring
0.25 cm x 0.25 cm. Supervisor's preliminary findings were "the skin looks like it comes from client bumping or rubbing his head against something." There was no further information regarding investigation into how this injury of unknow origin occurred.
m. Incident Report 09/24/2023:
Individual #2 hit his head on the wall and reopened the scab measuring 0.9 x 0.8 cm on his forehead. There was no further information regarding investigation into how this injury of unknow origin occurred.
n. Incident Report 10/13/2023:
Staff observed a bruise on the right side of Individual #2's back in the middle measuring
4 cm x 2 cm and a scratch on his lower right side of his back. Supervisor's Preliminary Findings stated "it appears that [Individual #2] may have rubbed his back against something causing the bruising and scratch. He has been known to walk around in the living area, walking into objects due to him being vision impaired (legally blind). Three staff interviewed did not notice bruising, the fourth staff noticed the bruising when giving him a shower.
- A review of the section titled, Administrative Comments noted "[Individual #2] is being monitored until the bruise resolved. Also noted team is going to meet to come up with strategies that may help him. He appears to be over stimulated. Transfer is not an option at this time, but the team will discuss together to support [Individual #2] in all his areas of care."
There was no indication in this document regarding staffing ratios in place at this time of this incident.
o. Incident Report 11/10/2023:
"I (staff person) was assigned [Individual #2] while giving PM care and shower time. [Individual #2] was standing up and moving around he rubbed his head on shower cart rail causing an old womb (sp) to reopen, notified 'supervising' and nursing." .
- A staff attendance sheet was attached to this incident dated 12/09/2023, signed by the staff person who was performing PM care and shower for Individual #2 when the above injury occurred. This form was an acknowledgement that the staff person in question understood the following information: "During shower time [Individual #2] should be seated in the shower chair with the seat belt fasten."
- A review of 90 Day Physician Orders for the period from 05/15/2023, through orders dated 01/09/2024, revealed the identical statement throughout all orders; "Shower at 2:30 PM with maximum staff assistance of 2. Ambulate [as desired] with 2 staff in hallway and for bedroom, every 30-minute checks. Ambulate to bathroom 10AM, 12 N, 2PM and 5PM with 2 staff to stay with Individual at all times due to visual deficit." In addition, Individual #2 has a standing order for "shower chair with seat belt."
In further review, there was no evidence that the IDT had examined the staffing ratio in place for Individual #2 at the time of this injury.
p. Incident Report 12/29/2023:
"At 3:35AM, the nurse provided Individual #2 his feeding and morning medications. After feeding but before leaving the area, the nurse observed Individual #2 standing in front of his chair holding both his hands on the side of the chair. The nurse left the area to continue administering medications to other residents. Staff reported to this nurse that Individual #2 fell on the floor. A full body assessment was performed by nursing, a small cut was noted below his right eyebrow. Bleeding noted, pressure was applied, and the bleeding stopped. 911 was activated and Individual #2 was transported to the hospital for additional evaluation and possible treatment."
- An additional description of the incident from the assigned staff on 12/29/2023, revealed the following: "I had Individual #2, was on the computer monitoring him doing my training and at 3:40 AM while the nurses were feeding Individual #2, after feeding I heard a loud bang, I walked towards the sound and Individual #2 was on the floor bleeding from his eye, also there was blood on the floor. Nurse was in the area near the medical cart turned back around to attend to Individual #2's injury."
- On 01/02/2024, a mini-IDT was held and reviewed the above incident that occurred on 12/29/2023, where Individual #2 fell and hit his head during a tube feed at 3:34 AM. Individual #2 was placed on 1:3 medical staffing ratio for all three shifts defined as 1 staff to three persons. It was also listed that "On 01/02/2024, nursing recommended that staffing ratio be discontinued on 1st and 2nd shifts and remain on 3rd shift times seven days, 01/02/2024 thru 01/08/2024."
q. Incident Report 01/07/2024:
Description of Injury/medical treatment: "Resident have difficulty breathing and chest congestion. Pox 90% on room air, stuffy nose, cough and drooling of secretion present. Bilateral lung crackles and rales present on chest [listening to chest sounds]. Sent Resident to [name of hospital] via 911 for respiratory distress."
- "Management Follow Up/Outcome/Corrective Action - Diagnosis: subacute/bilateral closed rib fractures." When asked if an investigation was in place for the above incident, interview with the Performance and Quality Improvement Coordinator on 02/01/2024, at approximately 10:00 AM, noted that an investigator had been assigned to complete this investigation. However, this interviewee was unable to indicate when the investigator had been assigned or what progress had been made in the completion of said investigation by this date, 02/01/2024.
- On 01/09/2024, a mini-IDT was held. Under the section titled, Team Discussion, the team referenced an incident report dated 01/07/2024, in which Individual was sent out to the emergency room due to difficulty breathing, chest congestion, and bilateral lung crackles. This individual's discharge diagnosis was a sub-acute bi-lateral closed rib fractures.
He was placed "on 1:2 staffing ratio on all three shifts effective 01/07/2024, instead of 1:3 on 3rd shift." ... "The IDT agreed to keep [Individual #2] on a 1:2 staffing ratio [times] 7 days until his next follow-up meeting on 01/16/2024."
r. Incident Report 01/15/2024:
"At just before 7:00 AM, [Individual #2] was sitting in his w/c (wheelchair) outside his bedroom in Apartment 2 hallway. Staff [name of staff] was sitting in [Individual #2's] bedroom doorway writing his paperwork. I entered [Individual #2's bedroom] and closed the door gently. Staff was dressing [name of resident]. As I was preparing [name of resident's] tube feeding, [name of staff] called my name and showed me a cut on [Individual #2's] left hand 4th finger. I saw a small cut with minor bleeding and applied pressure. I saw blood on door frame and several drops on the hallway floor. 911 was activated. Upon arrival, pressure removed, and EMS (Emergency Medical Services) applied a dressing before transport to [name of hospital]." This description of the incident was written by the nurse on duty.
- Supervisor's Preliminary Findings include the following: "Laceration to left hand 4th digit observed. Scan blood noted on door of Room 124 and hall floor outside Rooms 124 and 126. [Individual #2] unable to answer yes/no questions effectively. [Individual #2] with 1:2 staffing at the time of discovery. RN provided first aid, activated 911/EMS and attempted notification to designated contact." Incident was put under investigation.
- An investigation was initiated on 01/17/2024, but was not completed at the time of the survey. Further review of Individual #2's record revealed a document post emergency room visit titled, After Visit Summary dated 01/15/2024. This document revealed Individual #2's had a traumatic amputation of portions of the fourth and fifth fingers. There is a comminuted fracture (type of broken bone that occurs when a bone breaks into three or more pieces) of the fourth distal phalanx with displacement/distraction of fracture fragments.
- On 01/16/2024, mini-IDT was held and noted [Individual #2] should be showered by two staff persons. This individual "is currently on a 1:1 staffing ratio effective 01/15/2024, and the IDT will follow up on 01/19/2024."
- On 01/19/2024, mini-IDT was held and noted the following: "Per the HSS (Health Service Supervisor), [Individual #2] sustained an unwitnessed injury to his left hand (4th and 5th fingers)." It was noted that on 1/15/2024, Individual #2 was on 1:1 enhanced staffing across all shifts. He "requires constant redirection from 1:1 staff to maintain integrity of dressing. He often requires 2 staff and 2 nurses to perform his wound care effectively and safely. He does better with male staff 1:1. Team will follow-up on 02/14/2024, to discuss [Individual #2's] 1:1 status."
D. Interviews
When asked to define a standard staffing ratio, interview with the AED on 02/02/2023, at approximately 11:00 AM, stated that either a one staff to 3 person ratio (1:3) or a one staff to four person ratio (1:4) is the standard staffing ratio unless there are extenuating circumstances, e.g. Covid, snow storm. In those cases. staffing would revert to regulatory standards of one staff to eight Individuals.
When questioned regarding the facility process to establish 1:1 supervision protocols for an Individual, the AED stated that "We don't want to leave it on when they don't need it." In regards to Individual #2, this interviewee explained that "a meeting was held yesterday, 02/01/2024, with the PQI (performance and quality improvement) representative and it was determined that if [Individual #2] was on a 1:1 when he falls at least the 1:1 can witness the falls. The AED also explained that Individual #2 still continues to experience falls and injuries even when on enchanted supervision protocol of 1:1 staffing.
The AED further stated that the facility continues to seek alternative placement for Individual #2 in a smaller setting within the provider agency as he would do better in a smaller environment. Individual #2 had previously resided in a 5 bed residential home prior to his placemnt at this facility in 8/2020 due to closure of his previous residence setting.
In further interview with the qualified intellectual disabilities professional, Clinical Director and the AED on 02/01/2024, at approximately 10:45 AM, none of these interviewees were able to provide consistent, definitive information on the changing supervision protocols for Individual #2 throughout the period from 1/27/2023, through 1/15/2024, during which time he experienced significant multiple injuries.
Plan of Correction:Corrective Action for Affected Individual:
On January 15, 2024, Individual #2 was placed on a 1:1 staffing ratio secondary to an injury beyond first aid to his left hand and the number of incidents occurring over the past quarter. The Qualified Intellectual Developmental Professional, Executive Director, Psychologist, Health Service Supervisor, and Assistant Health Service Supervisor met on February 2, 2024, and recommended a 2:1 staffing ratio during waking hours and 1:1 when asleep. A Mini Interdisciplinary Team was held, and consents received on February 2, 2024, for the restrictive procedure. Documentation of the meeting will be recorded on a Mini Interdisciplinary Team form and sent to the Executive Director for verification of completion, in addition; filed in Individual #2 active unit chart for future reference.
Effective February 2, 2024; for thirty (30) days the Psychologist/designee will train all staff currently working with Individual #2 on the staffing ratio (2:1 defined as 2 staff to 1 individual) and the documentation on the 2:1 Log Form documents checks completed by the assigned staff for identifying current activity every 15 minutes. During the training it will also be emphasized the purpose and staff responsibility during the 2:1 assignment.
Beginning 2nd Shift February 2, 2024, the Shift Supervisor(s) on duty is responsible for monitoring the 2:1 ratio and verifying the 2:1 log has been completed and is being implemented according to the training validating the training was effective. The monitoring will occur three (3) times per shift. Any noted concerns will be recorded on the back of the 2:1 log defining how the concerns is being addressed at the time of discovery. Any issues and concerns will be reported to the Executive Director by the end of the shift and actions will be taken to correct or improve any area where supervision of Individual #2 could potentially lead to injury. The Shift Supervisors will initial the 2:1 log verifying the training has been effective.
Effective 2nd shift on February 2, 2024, for the next sixty (60) days, the Department Heads (Directors and Assistant Directors of programs and Qualified Intellectual Developmental Professional) will be assigned via a schedule reviewed and emailed out to all participants. The Department Heads are responsible for monitoring and documenting the above process at (1) time per shift on each shift to include first, second and third shift. The Department Heads will conduct unannounced visits and a review of the 2:1 log one time per shift as described above, to include their initials and questions about what was observed on the 2:1 log. Any noted concerns will be addressed at the time of discovery and reported to the Executive Director and immediate actions will be taken to correct or improve Individual #2's health and safety, or any area where supervision of Individual #2 could potentially lead to injury.
Initiated on February 5, 2024, and over the next thirty (30) days training is being conducted with all facility staff on visually impaired individuals and client rights/protection. All training will be documented on a Staff Attendance (SA) Sheet which will be sent to the Executive Director for verification of completion and maintained in the Staff Development Office.
All new hires will be trained within the two (2) weeks of training days of hire regarding policies for visually impaired and client rights and protection. Verification of the training will be documented on the Orientation Worksheet and maintained in the Staff Development Office.
After the above training is completed all facility staff will be trained as needed in the above policies and verification of the training will be documented on a Staff Attendance (SA) Sheet which will be maintained in the Staff Development Office.
A team meeting was held February 7, 2024, to review our current process, long term protection and evaluate any other strategies around protecting Individual #2 from injury, including a daily schedule/routine. Documentation of the team meeting was recorded on a Mini Interdisciplinary Team form and sent to the Executive Director for verification of completion and filed in Individual #2's active unit chart.
On or before March 8, 2024, a long-term evaluation of the supervision of Individual #2 by the team, to include clinical supports, will be conducted to review how a systemic reduction of accident/injury can occur and will be recorded on a Mini Interdisciplinary Team form and sent to the Executive Director for verification of completion and filed in Individual #2's active unit chart.
Procedure for Identifying Potentially Affected Individuals:
On February 23, 2024, the Psychologist and local Program Quality Improvement Department developed a spreadsheet of the last six (6) months of individual(s) who could be potentially affected, to include - 2 or more incidents of the same type, incidents that resulted in an increased level of supervision for safety and individuals that have had increased levels of supervision on/off multiple times.
On or before March 12, 2024, the team will meet on the list of individuals identified, on the above developed spreadsheet, to review their current Individual Program Plan and put any necessary training and/or schedule in place to ensure client protection(s). The team meetings will be documented on a Mini Interdisciplinary Team form and placed in the individual's active unit chart. A copy of the meeting will be sent to the Social Service Supervisor and/or designee to verify completion. Any follow up to the Mini Interdisciplinary Team's will be monitored and documented by the Qualified Intellectual Developmental Professional on the Mini Interdisciplinary Team form.
Corrective Actions/Systematic Changes:
On February 18, 2024, a policy was created to support why, when and how long enhanced supervision is warranted including a process for fading the restrictive level of supervision. The Psychologist, Local PQI Director/designee, Executive Director, and Physician will be trained on the policy no later than March 8, 2024.
A checklist will be developed for any individual residing at the facility with enhanced supervision, documenting the purpose, approval/reduction/removal, start date/end date, and accompanying signatures from Psychologist, Executive Director, PQI Director, HRC, and Physician which will be utilized and attached to the Mini Interdisciplinary Team for consistency and protection of client treatment.
Monitoring of Corrective Actions and Systematic Changes:
Beginning March 5, 2024, the Executive Director, Psychologist, and Local Performance Quality Improvement Director/designee will review all enhanced supervision prior to being initiated and prior to being reduced or removed. This will be documented on the Restrictive Supervision Administrative Review developed on February 18, 2024, for all enhanced behavioral-based increased supervision.
On February 29, 2024, a full report of all incidents over the time period of six (6) months at the facility was developed to assist the Incident Review team in identifying any trending, analysis, or patterns to behavior. This report will be reviewed during the Incident Review Meeting, documented and maintained with the minutes. In addition, the full report of incidents will be given to the Merakey Corporate Quality Compliance Organization for their review and feedback for a period of sixty (60) days. Beginning March 1, 2024, the full incident report will be updated weekly by the Local Performance Quality Improvement Department.
Residential Managers will continue to observe and document the monthly audits regarding the staff interactions with the individuals at the facility and addressed before the end of the shift any health and safety concerns at the time of the observation. A copy of the audit will be maintained in the Executive Directors office. In addition, the Resident Manager will report any health and safety observation to their supervisor for any corrective action. In addition, if a team meeting is warranted the Qualified Intellectual Developmental Professional will be notified and schedule and document the team meeting on a Mini Interdisciplinary Team form.
The Human Rights Committee will review and approve all enhanced coverage quarterly at the Human Rights Committee Meeting.
Persons Responsible for Monitoring Corrective Actions:
The Executive Director will report any anomalies to the Senior Executive Director at the monthly Director's meeting to further address via systemic corrective actions.
483.420(d)(3) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must have evidence that all alleged violations are thoroughly investigated.
Observations:
Based on record review and interview with administrative staff, the facility failed to have evidence that all alleged violations are thoroughly investigated for two of three sample Individuals final investigations which were reviewed. This practice is specific to
Individuals #1, and #11.
Findings included:
A review of facility incident reports and investigations for the period from 07/01/2023, until 02/05/2024, was completed on 02/01/2024, from 9:00 AM to 12:00 PM, on 02/02/2024, from 8:30 AM to 1:30 PM and on 02/05/2024, from 8:30 to 10:30 AM. This review revealed the following:
Individual #1
1. A review of a final investigation report dated 08/29/2023, was completed on 02/01/2024, from approximately 10:00 AM to 11:00 AM. This investigation was completed in response to an incident involving Individual #1 that occurred on 06/23/2023. This incident report noted the following:
"I (Direct Support Professional) was transporting clients to the dining room and I went over to help [Individual #1] with his liquids. While I was standing next to him he started choking on his food so I called for the nurse and she came over and helped."
A second Direct Support Professional reported the following: "While meal monitoring and performing my meal monitor duties, I heard nursing call for another nurse. Then I walked over to find out what is going on. That's when nursing was performing the Heimlich. At that point, I ran into inform shift supervisor and nursing staff. Shift supervisor then called STAT to dining room."
The description of the injury and medical treatment completed by the nurse revealed the following: "Alerted by staff that client was choking during dinner. Heimlich was performed and successful. Client vomited chunk of meat. Vital signs were taken and within normal range, 911 was called and client sent out for further evaluation. Chunk of meat was about the size of a quarter."
2. A subsequent review of the record of Individual #11 revealed an Occupational Therapy
Self-Feeding Evaluation dated 12/28/2022. This evaluation contained the following information regarding feeding protocols for this Individual:
- encourage independent feeding first, then hand over hand assist and dependent assist as needed.
- staff to provide assist to place cup in [Individual #1's] hand for independent drinking with verbal and physical prompt to slow rate and intake."
When questioned regarding feeing protocol and staff assignments during meals, interview with the Executive Director on 02/02/2024, at approximately 12:00 PM, revealed that there are three Individuals at each table during mealtime. One Individual is fed by an assigned staff person, one Individual requires minimal support/supervision, and one Individual is able to feed independently. Although the one staff is feeding a specific Individual, this staff is also responsible for ensuring the other two Individuals are following their diet orders as prescribed by their physician. This information can be found on a card on the table."
3. A review of the investigation findings action plan dated 07/06/2023, included the following findings information:
- meal monitors will be trained to inspect all consumer's food for the correct texture of all food items to to ensure consumer's safety before given to staff to serve. Meal monitors are also directed to report any/all issues with food or consumers to shift supervisor, nursing, or residential managers as soon as possible.
- a four week action plan was put in place that includes but not limited to training/retraining of direct care personnel, and entire kitchen staff on food textures, and preparation. In addition, kitchen director will periodically observe the staff preparing food to ensure correct textures are prepared/served.
- target kitchen staff received a three day suspension.
- as part of the initial action plan, dietician continues to do meal tray audits (5 trays per day).
- as part of the initial action plan, DSP were trained on checking/scooping out the food to make sure correct texture is being served to all the individuals, including those who eat independently.
Although the investigation focused and identified issues with food texture, there was no indication that the investigation had addressed staff implementation of the existing feeding protocol and supervision guidelines.
Individual #11
A review of an investigation report regarding Individual #11 was completed on 02/01/2024, from approximately 9:00 AM until approximately 10:30 AM. This review revealed an incident that occurred on 07/18/2023, and an investigation of that incident that was initiated on 07/19/2023, and concluded on 08/01/2023. The incident that occurred was as follows:
"On July 18, 2023, [Individual #11] was in the dining room for dinner and began to have a behavior. It was reported by a staff person that [Individual #11] was screaming, pushing the table, attempting to remove her shirt and asking for a soda. [Individual #11's] staff person told [Individual #11] that she could not have a soda. A facility nurse went over to the [Individual #11's] table in an attempt to calm [Individual #11] down." A verbal altercation ensued in front of [Individual #11] between the facility nurse and [Individual #11's] staff person which involved cursing by the staff person. [Individual #11] continued to scream during the altercation between the facility nurse and staff person. The facility nurse left the area to report the incident and the staff person yelled, "You can call 'who ever' you want to call."
A review of Individual #11's behavior support plan dated 05/23/2023, through 05/22/2024, revealed that [Individual #11] has no restrictions regarding soda like beverages within this Indvidual's behavior plan, or current dietary guidelines. This plan does not outline any restrictive procedures that limit acquisition of items during a behavior outburst. Subsequent interview with the Clinical Director, and the Executive Director on 02/01/2023, at approximately 10:10 AM and 10:45 AM, respectively confirmed that Individual #11 has no restrictions on having a soda beverage if requested.
Further review of the investigation document revealed a section titled, "Administrative Review" dated 08/08/2023. This review indicated that "The Administrative Review Committee (ARC) examined all the evidence presented. Based on witness testimony, [Individual #11's] staff person's admission of using profanity in the presence of
[Individual #11] ...the ARC confirms abuse/psychological as the incident involved potential to cause mental or emotional harm."
There was no indication within this documentation that the denial of a food item was discussed by the administrative review group as part of the investigation.
Plan of Correction:Corrective Action for Affected Individual:
Individuals #1 and #11 investigations dated July 6, 2023, and June 23, 2024; respectfully will be reviewed by several members – Human Resources, Local PQI Department, the Investigator, Labor Department (if warranted), Executive Director, and Health Service Supervisor. The Executive Director will review the investigation packet before the Administrative Review Committee to identify any areas of discrepancies and/or if additional information is needed to make a determination on the investigation. A determination will not be made until all identified discrepancies have been remedied and all information needed to make a determination has been reviewed and documented.
On February 2, 2024, the Executive Director requested a Certified Investigator to open a client rights investigation for Individual #11.
The team members upon further review will determine if an additional investigation is warranted or if an investigation needs reviewed for additional details, retraining, or revisions to the individuals program plan. Verification of the review will be documented on the Administrative Review Form.
Procedure for Identifying Potentially Affected Individuals:
On or before February 29, 2024, the local Performance Quality Improvement Department will develop a spreadsheet for the last six (6) months identifying all investigations and conduct a review of 10% all individuals who could be potentially affected by a serious incident.
On or before March 12, 2024, 10 % of the investigations identified will be reviewed by several members – Local Performance Quality Improvement Director, Executive Director, Psychologist and Health Service Supervisor. The team members upon review will determine if an additional investigation is warranted or if an investigation requires retraining, or revisions to the individuals program plan. Verification of the review will be documented on the Administrative Review form.
Corrective Actions/Systematic Changes:
Beginning February 19, 2024, for a month, all Merakey employees will be retrained on Incident Reporting and Abuse, Neglect, and mistreatment. All training will be documented on a Staff Attendance (SA) Sheet which will be sent to the Executive Director for verification of completion and maintained in the Staff Development Office.
All new hires will be trained within fourteen (14) days of hire regarding policies for Incident Reporting and Abuse, Neglect, and Mistreatment. Verification of the training will be documented on the Orientation Worksheet and maintained in the Staff Development Office.
After the above training is completed all facility staff will be re-trained as needed in the above policies and verification of the training will be documented on a Staff Attendance (SA) Sheet which will be maintained in the Staff Development Office.
If an incident report requires an investigation, the investigation will be reviewed at five (5) days and again at the conclusion of the investigation. The investigations final review will consist of several members – Human Resources, Local Program Quality Improvement Department, the Investigator, Labor Department (if warranted), Executive Director, and Health Service Supervisor.
Monitoring of Corrective Actions and Systematic Changes:
Beginning the week of March 12, 2024, all incident reports will be reviewed every other week by the Incident Review Team, consisting of a representative from each of the various departments – residential, clinical, nursing, and social service to ensure proper health and safety protections.
Beginning March 1, 2024, for the next six (6) months the Quality and Compliance Operations team will review all investigations completed monthly to ensure client protections are addressed and monitored thoroughly. All feedback from the Quality and Compliance Operations team will be sent to the Certified Investigator and Local Performance Quality Improvement Director via email regarding investigative fidelity and will be addressed within one (1) month.
Persons Responsible for Monitoring Corrective Actions:
The Local Performance Quality Improvement Director will report any anomalies to the Senior Executive Director at the monthly Director's meeting to further address via systemic corrective actions.
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