Initial Comments:
A focused fundamental survey was conducted on November 6, 7, and 8, 2023 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 three and the sample consisted of two individuals. Four 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 documentation review and staff interview, it was determined that the facility failed to ensure all allegations of abuse, neglect, or mistreatment were reported immediately to administration. This was noted for two investigations reviewed into alleged psychological abuse. (Individual #1)
The findings included:
A. Facility investigations from November 2022 through present were reviewed on November 6, 2023. This review revealed an allegation of verbal/psychological abuse was reported to the facility by Adult Protective services on April 28, 2023. On May 1, 2023, the Assistant Vice President (AVP) was contacted by the Vice President of Human Resources regarding an employee who wanted to report abuse. The facility investigation was started on May 1, 2023. During an interview with the AVP it was revealed that the allegations were discovered while investigating a separate incident. A facility staff person stated during the investigation interview that the target of the investigation would yell and can be "over the top" when interacting with Individual #1.
B. Further review of this investigation packet revealed that this was witnessed by a several staff persons but not reported to administration. It was noted in the investigation as occurring on three separate occasions. This allegation of verbal abuse was confirmed through witness statements. The target of the investigation was suspended from working with the individuals on May 1, 2023.
C. The AVP was interviewed on November 7, 2023, at 1:30 PM. The AVP confirmed that the allegation of verbal abuse for Individual #1 was not immediately reported to administration.
Plan of Correction:W0153 STAFF TREATMENT OF RESIDENTS
The facility staff must report allegations of mistreatment, neglect or abuse, as well as injuries of unknown origin immediately to the administrator and other officials in accordance with State law.
This deficient area is revealed by allegations of alleged abuse on 4/28/23 and 5/1/23, the first by a call from Adult Protective Services on a staff using a residents IPAD as a means of punishment for misbehaving, and the second by a call from Human Resources on a staff allegedly "yelling/"over the top" as an alleged incident of psychological abuse.
Both incidents were reported late, and both incidents, were concluded as "confirmed incidents of psychological abuse". It should be noted that both "targets" of the investigations received appropriate discipline, one target relocated to a larger facility and one target, suspended, retrained and subsequently changed from full-time to call-in status.
As part of the facility action due to these allegations, and subsequent confirmed psychological abuse, the governing body that included administration, nursing, dietician, and QIDP met with Canaan Street staff in regard to three areas: Communication for all Interdisciplinary Team Members, Review of all Dietary Orders and plans, and review of all Behavior Support Plans, including Individual #1 and all other residents (2) who could be adversely affected by the deficient practice. Through the investigation processes, it was determined that there were changes within resident profiles that required more team involvement in complicated dietary plans and changes in behaviors that required review and modifications. There was also "staff conflict" that required Human Resources guidance to provide "separation" of staff members who were incompatible and interfering with the care and support of the Canaan Street individuals.
The entire team meets at the Canaan Street site on a Monthly/Bi-Monthly basis for Incident Management/Program Audit, as an additional component of the facility action to the incidents that occurred in April/May 2023.
To ensure that the deficient practice of "late reporting" does not reoccur, the facility will implement the following corrective action and systematic change:
- All residential staff will be in-serviced in on the agency's Incident Management policy via a written documented test that can be maintained on file for review.
- Monthly/Bi-monthly Incident Management/Program Audit Meetings at the site will continue to be conducted with all Interdisciplinary Team members. These meetings will ensure that all team members, clinical and administration, are aware and reactive to "resident changes" that can be addressed by the QIDP and the Interdisciplinary Team process, and "staff issues" that need to be addressed for better continuity of services and supports for the individuals (Individual #1 and all other individuals) of the Canaan Street program.
The Monthly/Bi-Monthly Incident Management/Program Audit meetings will also be a means of monitoring the corrective actions that have been implemented into the plan of correction to prevent a re-occurrence of the deficient practice identified in W0153. The Assistant Vice President, in conjunction with the Program Director, will be ultimately responsible for ensuring that the plan of correction is sufficiently implemented to eliminate any reoccurrence of the deficient practice identified in W0153.
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 documentation review, record review, and staff interview, it was determined that the facility failed to thoroughly investigate an unusual incident for one individual. (Individual #1)
The findings included:
A. Facility incidents and investigations from November 23, 2022 through November 5, 2023 were reviewed on November 6 and 7, 2023. This review revealed the following:
B. Individual #1
1. A review of facility documentation and review of a hospital emergency room discharge summary was conducted on November 6 and 7, 2023. This review revealed that on October 23, 2023 at 9:50 PM Individual #1 treated at a local hospital emergency room for an adverse reaction to a psychotropic medication. The hospital discharge summary revealed that Individual #1 was sent to the ER after being administered an extra dose Zyprexa. Individual #1 was administered Zyprexa on the night of October 22, 2023. Individual #1 was then administered Lybalvi on the morning of October 23, 2023. Review of current physician orders revealed that Zyprexa was discontinued on October 19, 2023. However, the Zyprexa was administered in error on October 22, 2023. Staff noticed Individual #1 was lethargic due to the additional dose of Zyprexa being administered. Facility staff called an ambulance to transport Individual #1 to the ER for treatment. Individual #1 was treated and subsequently discharged back to the facility later that evening.
C. Interview with a facility nurse and the Qualified Intellectual Disabilities Professional (QIDP) on November 7, 2023 at 9:00 AM confirmed that a medication regimen change had recently occurred on October 19, 2023.
D. Neither an incident report or a formal investigation regarding the medication error and the subsequent adverse reaction were not completed by the facility.
E. Interview with the Assistant Vice President (AVP) on November 7, 2023 at 2:00 PM confirmed that the facility failed to thoroughly investigate one unusual incident for one individual.
Plan of Correction:W0154 STAFF TREATMENT OF CLIENTS
The deficiency relates to Individual #1, and an apparent medication error, an extra dose of a psychotropic medication (Zyprexa/Lybalvi) that resulted in an emergency room visit on 10/23/23. Through the DOH survey process, via interview of the QIDP and facility nurse, available documentation acknowledged that there had been a medication regimen change. However, since there was no formal investigation by the facility, there was no clarity as to a possible medication error and subsequent adverse reaction for Individual #1.
Based on the findings of the deficient area noted in W154, and lack of a formal investigation related to a possible medication error, the following corrective actions and systematic changes will occur to prevent reoccurrence of the deficient practice:
- The Assistant Vice President and Health Services Manager will conduct a thorough investigation of the events that occurred to Individual #1 that included a psychotropic medication change, and subsequent emergency room visits.
- Following the results of the investigation, an element of the facility action will include a reeducation on the protocols related to "treatment beyond first aid" (emergency room visits), and protocols for psychotropic medication changes. This will include:
o Review of Incident Management Bulletin and Incident Management Policy
o Facility practices and procedures to communicate psychotropic medication changes
Physician Orders
Medication Administration Records
Nurses Remarks
Staff Communication Logs
Communication to QIDP for Family/Health Care Decision Maker (Informed consent) and Human Rights Committee Approval
The facility will utilize Monthly/Bi-Monthly Incident Management/Program Audit as a means to monitor the corrective actions, and as a means to eliminate the deficient areas noted in W0154 from re-occurring.
The Assistant Vice President, in conjunction with the Program Director & Health Services Manager will be ultimately responsible for ensuring the deficient practice identified in W0154 does not re-occur.
483.450(b)(3) STANDARD
MGMT OF INAPPROPRIATE CLIENT BEHAVIOR
Name - Component - 00
Techniques to manage inappropriate client behavior must never be used for disciplinary purposes.
Observations:
Based on observation, record review, and staff interview, it was determined that the facility failed to ensure interventions to manage inappropriate client behavior were employed with sufficient safeguards and supervision. This applied to individual. (Individual #1)
The findings included:
Individual #1
A. Facility investigations from November 2022 through present were reviewed on November 6, 2023. This review revealed an allegation of psychological abuse was reported to the facility by Adult Protective services on April 28, 2023. This allegation states that a staff member takes away Individual #1's iPad if she is misbehaving. There were no specific dates or times this occurred. A Certified Investigation was initiated.
B. Further review of this investigation revealed the alleged psychological abuse to be confirmed by the Individual #!, as well as one Resident Assistant staff, who saw target staff take away the iPad on three or four separate occasions.
C. The Assistant Vice President (AVP) was interviewed on November 7, 2023, at 1:30 PM. The AVP confirmed that staff implemented a restrictive measure that was not addressed in Individual #1 ' s Behavior Support Plan. The target staff is no longer is employed by this facility.
Plan of Correction:W0286 MANAGEMENT OF INAPPROPRIATE CLIENT BEHAVIOR
The deficient area notes that techniques within a Behavior Support Plan must never be used for disciplinary purposes. This deficient area became evident when an anonymous phone call was made to Adult Protective Services regarding a staff person using Individual #1's IPAD as a means of discipline for misbehaving, more specifically taking away Individual #1's IPAD when misbehaving. This practice had occurred on several occasions. Through investigation, the certified investigator determined that the allegation was "confirmed psychological abuse". The target of the investigation was termed from the Canaan Street site.
As a facility action following the investigation, Individual #1, and the other two residents who reside at the program, had their respective Behavioral Support Plans reviewed by the QIDP/Program Specialist on 6/7/23, and all three residents (including Individual #1), had modifications implemented into their respective Behavior Support Plan.
- Individual #1: Individual #1 was on a Behavior Support Plan to address: Picking at her Skin, Physical Aggression, Verbal Aggression, Attempted Elopement/Elopement, Suicidal Ideations and the inclusion of "bedwetting", ruling out medical causation, will implement 2-hour bathroom checks (added 6/14/23). Use of Individual #1's IPAD is not and never was an item for use as punishment/reinforcer.
- Individual #2: Implementation of protocols to address nighttime insomnia
- Individual #3: Implementation on interventions and protocols to improve day program attendance.
All staff were in-serviced on the new modifications within the Behavior Support Plan.
To address the deficient area identified in the CMS-2567, the facility, under the guidance of the QIDP, will complete another review of Individual #1's Behavior Support Plan to assess whether the current plan remains appropriate, and/or modifications are required to address Individual #1 behavioral and emotional needs.
In addition, the remaining two residents, others who could be affected by the deficient practice) will have their current Behavior Support Plans reviewed by the QIDP and team members for their effectiveness in addressing their respective target behaviors, and if necessary, modifications will be made and implemented into their program plans.
To monitor the effectiveness of the plan of correction, the facility will use Monthly/Bi-Monthly Incident Management/Program Audit Meetings to review progress, note modifications in plans, and/or document the effectiveness of the current plans. The Assistant Vice President, in conjunction with the Program Manager, will be ultimately responsible for the implementation of the plan of correction, oversight of progress and elimination in re-occurrence of the deficient areas noted in W0286.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on incident report review and staff interview, it was determined the facility failed to ensure that one individuals' medication was administered without error. (Individual #1)
Findings included:
Individual #1
A. On October 23, 2023, Individual #1 received an extra dose of Zyprexa which resulted in an adverse reaction. See W154 for further details.
B. Interview with the Program Director on November 7, 2023, at 1:30 PM confirmed that Individual #1 was administered an extra dose of medication and this resulted in an adverse reaction and subsequent treatment at a local emergency room.
Plan of Correction:W0368 DRUG ADMINISTRATION
This incident involves failure to provide medication without error, resulting in an extra dose of medication, and adverse reaction to a resident, an assessment at a local emergency room.
W0368 is affiliated with W0154 deficiency that cited the same circumstances, but lacked a thorough investigation into the medication error. As part of the corrective action, the Assistant Vice President and Health Services Manager will conduct a thorough investigation surrounding the October medication error and subsequent emergency room visits.
In addition, an element of the facility action will include a reeducation on the protocols related to "treatment beyond first aid" (emergency room visits), and protocols for psychotropic medication changes. This will include:
- Review of Incident Management Bulletin and Incident Management Policy
- Facility practices and procedures to communicate psychotropic medication changes:
o Physician Orders
o Medication Administration Records
o Nurses Remarks
o Staff Communication Logs
o Communication to QIDP for Family/Health Care Decision Maker (Informed consent) and Human Rights Committee Approval
The facility will utilize Monthly/Bi-Monthly Incident Management/Program Audit as a means to monitor the corrective actions, and as a means to eliminate the deficient areas noted in W00368 from re-occurring.
The Assistant Vice President, in conjunction with the Program Director & Health Services Manager will be ultimately responsible for ensuring the deficient practice identified in W0368 does not re-occur.
|