Saratoga County Maplewood Manor

Based on medical record review and staff interviews during a complaint investigation (Case # NY00098507) it was determined that the facility did not investigate a situation of potential abuse, neglect or mistreatment in a timely manner and did not prevent further potential abuse while the investigation was in progress. Additionally, the facility did not ensure that all alleged violations involving mistreatment, neglect and abuse were reported immediately to the adminstrator of the facility. Specifically, when it was reported to a registered nurse supervisor (RNS # 1) on 3/5/11, that a certified nursing assistant (CNA #1) might have digitally disimpacted a resident who had been previously diagnosed as having a rectal fistula, the facility Administrator and/or Director of Nursing (DON) were not notified, the accused CNA (CNA # 1) was allowed to finish her shift, and the CNA did not receive instructions to not report again to work until the completion of the facilities investigation. The facility DON and Administrator were not made aware of the situation until 3/8/11 and an investigation was not started until 3/11/11 when staff were interviewed by the facility administrator and DON for the first time. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following.

Resident # 1
The resident was admitted to the facility on 9/15/10 with diagnoses of dementia, osteoporosis and hypertension. The most recent Minimum Data Set (MDS) assessed the resident to have long and short term memory impairment and severely impaired cognitive skills for decision-making.

In a packet of papers described by the facility DON as part of the facility investigation there was a note to the facility DON from the evening supervisor (RNS # 1), and statements from three CNA's (CNA #'s 1,2 and 3). The note from RNS # 1 read, "(DON), Today I was approached by two CNA's (CNA# 2 & CNA # 3) regarding CNA # 1. They were both very concerned about hands-on care that CNA # 1 was providing to Resident #1. Apparently, they felt she (CNA # 1) was disimpacting her while the resident was struggling to have a bowel movement. I met with and obtained statements from all 3 employees; they are attached. Please feel free to contact me regarding this issue. An undated statement signed by CNA #3 (the CNA stated that she wrote it on the evening of 3/5/11) attached to RNS # 1's note, documented that CNA # 3 was assisting CNA # 1 as she was toileting Resident #1. CNA #3 documented that CNA # 1 was on her knees (next to the resident who was sitting on a shower chair placed over the commode) and had her hand on the resident's buttocks and was pulling out large amounts of BM. CNA #3 described CNA # 1's activity, "CNA # 1 pulled her hand that had a glove on it. It was covered in BM so I knew she had to be in the rectum." CNA # 3 went on to write, "I told CNA # 1 that the nurse should clean the resident's wound when she did the treatment but she (CNA #1) continued to rub the sore with a rough cloth. " A statement contained in the packet of papers written by CNA # 1 docuemnted that the resident was struggling to have a bowel movement and so CNA # 1 pressed on her stomach and on the outside of her rectum to help her along.

During an interview on 3/30/11 at approximately 3:00 pm, licensed practical nurse (LPN # 1) stated that on 3/5/11 at approximately 5:00pm she was approached by a CNA (CNA # 2) who indicated ( by verbally describing and demonstrating) to her that CNA # 1 had just disimpacted Resident #1, as the resident sat on a shower chair that had been placed over the toilet. LPN # 1 stated that she first reported it to the supervisor (RNS # 1) when she made rounds that evening at approximately 6:00 pm. At that time, RNS #1 interviewed CNA's # 2 and 3 who had apparently witnessed the alleged disimpaction. CNA # 1 had been sent out of the building to transport another resident to the hospital and was not interviewed until later in the shift. LPN # 1 reported that just before 11:00 pm, CNA # 1 was called down to the supervisor's office to be interviewed. When CNA # 1 returned to the unit, she seemed upset and then she left for the night as it was the end of her shift. LPN # 1 stated that she was not questioned again about the events of that evening and the alleged disimpaction until 3/11/11 when she was interviewed by the facility administrator and DON. At that interview she was asked to write a statement which she did.

During an interview on 4/6/11 at approximately 1:00pm, RNS #1 stated that on 3/5/11 as she was making rounds at approximately 6:30-7:00 pm, she was approached by LPN #1 who stated that she had been informed by CNA # 2, that CNA # 1 had disimpacted Resident #1 while the resident sat on a shower chair over the toilet. RNS# 1 then went and interviewed CNAs # 2 and 3. RNS #1 stated that both of the CNA's explained that the resident was sitting on a shower chair over the commode and CNA # 1 was kneeling next to the shower chair with her gloved hand under the resident. The CNAs demonstrated (one with extending one finger , the other extending three fingers) how CNA # 1 would put her hand under the resident and when she pulled her hand back out form under the resident, there was feces on her gloved hand. The CNA's reported that CNA # 1 performed this motion more than once and that CNA # 1 was also massaging the resident's abdomen with the other hand. Although CNA # 2 and 3 could not see CNA # 1's finger inside the resident's rectum, they both seemed to feel that CNA # 1 was disimpacting the resident and they both stated that CNA's could not disimpact residents. RNS #1 and a second RN supervisor (RNS # 2) interviewed CNA # 1 after she came back from her transport later in her shift. RNS # 1 reported that CNA # 1 stated during her interview that Resident # 1 was struggling to move her bowels and she could see hard stool so she rubbed the resident's belly with one hand and she was pushing on her butt, around her rectum with the other. She told us during the interview that she was using her finger to pull out feces and she was using her finger to scrape feces that was hanging out of the resident's rectum. She never denied doing it (disimpacting the resident). RNS # 1 then asked CNA #1 to write a statement and after that CNA # 1 left for the night. RNS # 1 remarked that after she read the statement that CNA #1 wrote, she actually thought that CNA #1 was disimpacting the resident and wondered if she really understood what disimpacting meant. RNS # 1 stated that we didn't tell CNA # 1 to go home early and we didn't tell her not to return to work until she heard from the administrator. I wrote a note to the DON and attached the copies of the statements the 3 CNA's had written and put it in a manila envelope and put it in the out-going box for her to see when she came in on Monday. I wrote it up as a potential for injury because CNA # 1 was working outside the scope of her practice. We didn't see any injury to the resident and we checked her during her treatment for the rectal abscess. I didn't call the Administrator or the DON to report the incident to them. I guess at the time, I didn't see it as willful abuse. When I look back at it I guess I should have called the administrator and made her aware of what had happened. After that night (3/5/11), no one spoke to me about the situation until 3/11/11 when I was interviewed by the administrator and the DON. I think that's when I was told the Health Department had been called.

In an interview on 3/22/11 at approximately 11:00am the facility DON stated that she was first made aware of a concern over a CNA disimpacting a resident on 3/8/11 when she found a packet of papers in her mailbox with a note from the RN Supervisor (RNS #1) and statements attached. The statements described a situation that involved allegations that CNA # 1 had disimpacted Resident # 1 on the evening of 3/5/11. The DON admitting having concerns after reading the note from RNS # 1 and the statements from the staff and brought the papers to the facility administrator's attention immediately. After discussion with the Administrator, the DON wrote-up counseling memos for the CNA's involved and placed the memos in the RN supervisor's mailbox for the supervisors to give to the appropriate employees. The DON recalled that the accused CNA (CNA # 1) was out on a medical leave on 3/8/11 and was not expected to be back for a while. She stated she didn't consider the situation to be abuse and therefore didn't investigate it but wrote up counseling memos because if CNA # 2 and #3 were present in the bathroom when CNA was allegedly disimpacting the resident, then they should have alerted someone right away and not waited until after they were finished in the bathroom. The DON stated that she didn't interview those involved until later in the week on 3/11/11.

10NYCRR415.4(b)(1)(ii)