St Johns Health Care Corporation
Deficiency Details, Complaint Survey, December 23, 2010
Regional Office: WRO--Rochester Area Office
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE
Severity: Potential for more than Minimal Harm
Corrected Date: February 18, 2011
The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Citation date: December 23, 2010
Based on record reviews and staff interviews conducted during an Abbreviated Survey (complaint #NY00094046) completed on 12/23/10, it was determined that for one of three residents reviewed for incidents and accidents, the facility did not thoroughly investigate unobserved falls to rule out abuse, neglect, or mistreatment. Specifically, the post fall assessment tool was partially completed, or not completed, to determine the cause of three falls for Resident #1. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:
Resident #1 was admitted on 9/27/10 with diagnoses including osteoporosis and a history of falls. The Fall Risk Tool, dated 9/27/10, shows the resident is high risk for falls. The current Comprehensive Care Plan (CCP) does not identify falls as a problem.
The Patient Progress and Status Notes, dated 9/30, 10/03, and 10/06/10, revealed that the resident was found in her room on the floor without injury.
Incident/Accident (I&A) Reports, dated 9/30 at 3:00 a.m., 10/3 at 11:59 p.m., and 10/6/10 at 4:05 p.m., show the resident was found in her room on the floor. These I&A Reports include post fall tool assessments that were not completed for 9/30 or 10/6, and partially completed for 10/3/10. There were no documented changes made to the CCP related to the falls on 9/30, 10/3, and 10/6/10.
When interviewed on 11/30/10 at 2:10 p.m. and 3:40 p.m., the Assistant Director of Nursing (ADON) said that the post fall tool should be completed within 24 hours of the fall and that if it is not in the chart, then it is lost or misplaced.
During an interview on 12/2/10 at 9:30 a.m., the Nurse Manager (NM) said that she was not present at the time of the resident's fall and that the nurse who completed the incident report should complete the post fall tool assessment and then she reviews them.
On 12/2/10 at 10:10 a.m. during an interview, the ADON said that the post fall tool should be started at the time of a fall and completed within 24 hours, as it helps to explain why the person fell, and the care plan could be reviewed at the same time.
When interviewed on 12/2/10 at 11:45 a.m., the Director of Nursing said that it is the responsibility of the NM to be sure the post fall tool assessment is completed.
The facility's policy for Incidents and Accidents, last revised 3/5/09, included to document all I&A Reports and to complete the post fall tool as directed.
[10 NYCRR 415.4(b)(3)]