Table of Contents
Ridge View Manor LLC
Deficiency Details, Complaint Survey, June 17, 2010
PFI: 3084
Regional Office: WRO--Buffalo Area Office
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: July 20, 2010
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: June 17, 2010
Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY00086951) completed 6/17/10, the facility did not have evidence that all alleged violations involving mistreatment, neglect or abuse were thoroughly investigated and that potential abuse was prevented while the investigation was in progress. One (Resident #1) of three residents reviewed for allegations of abuse had issues involving the lack of a thorough and timely investigation into an allegation of abuse and prevention of further potential abuse while the investigation was in progress. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The finding is:
1. Resident #1 has diagnoses including legal blindness, osteoporosis, osteoarthritis and history of a right arm fracture and surgical repair of bilateral hip fractures. Review of the Minimum Data Set (MDS) dated 3/22/10 revealed the resident has modified independence in cognitive skills for daily decision making, short term memory problems, is understood and understands. Additional review of the MDS revealed no documented evidence of depression, anxiety, mood or behavioral symptoms.
Review of a Nurse's Note written by a Registered Nurse (RN) Supervisor (#1) and a Daily Supervisor Report dated 6/5/10 at 8:35 AM revealed that a floor nurse reported that Resident #1 complained of left knee and hip pain "from being handled rough last PM". The Daily Supervisor Report was signed by three different RN Supervisors. A Daily Unit Report dated 6/5/10 also documented that Resident #1 complained of left knee and hip pain from being handled roughly last night.
Review of a Resident/ Employee Accident & Incident Report (A&I) completed by RN Supervisor #1 dated 6/5/10 at 8:15 AM revealed that Resident #1 complained of left knee and hip pain "as a result of being handled roughly last PM". The A&I documented that the family and Physician were notified and X-rays were ordered. Additional review of the 6/5/10 A&I revealed no documented evidence of a complete investigation, including staff statements, into the allegation of rough handling that occurred on 6/4/10.
Review of a "Report of Concern" (facility investigation) dated 6/10/10 revealed that an investigation was started on 6/7/10. Certified nurse aide (CNA #1) was identified as the CNA assigned to Resident #1 on 6/4/10 during the 3:00 PM to 11:00 PM shift, when the alleged "rough handling" occurred.
Review of Time Card Reports revealed that CNA #1 worked 14.9 hours on 6/5/10 and 14.0 hours on 6/6/10. Review of Daily Staffing Sheets for 6/5/10 and 6/6/10 revealed that the CNA #1 continued to provide care to residents on two different units.
Review of a facility policy entitled Suspected Resident Abuse Investigation dated 4/6/06 revealed the procedure for the "Initial Investigative Action" documents that upon notification of an incident, the Nursing Supervisor will take "appropriate action" with the person(s) involved.
When interviewed on 6/16/10 at 10:00 AM and 10:30 AM, the Licensed Practical Nurse (LPN) Unit Manager (UM) stated that she became aware of the "rough handling" incident involving Resident #1, on 6/7/10 when she reviewed the A&I. The LPN UM said she found out who the assigned CNA was, interviewed the resident and began to get written statements from staff members. The LPN UM explained the facility did not think there was credible evidence of abuse, neglect or mistreatment at the conclusion of their investigation on 6/10/10. The LPN UM confirmed that RN Supervisor #1 did not start a Report of Concern on 6/5/10 because the Social Worker keeps the "Report of Concern" paperwork locked in her office on the weekends.
When interviewed on 6/16/10 at 10:45 AM, the RN Inservice Coordinator/ Day Nursing Supervisor explained that an investigation can be initiated without the "Report of Concern" forms. She said the RN Supervisor should have called the RN Inservice Coordinator/ Day Nursing Supervisor or the Director of Nursing (DON) for direction on how to proceed with an investigation. The RN Inservice Coordinator/ Day Nursing Supervisor said she did not receive any phone calls regarding the incident when it happened and stated that CNA #1 should have been taken off the schedule pending results of the investigation.
During an interview on 6/16/10 at 1:00 PM, RN Supervisor #2, who worked from 11:00 PM on 6/5/10 to 7:00 AM on 6/6/10, said that he found out about the A&I that night but did not do any further investigation of the incident.
When interviewed on 6/16/10 at 3:00 PM, the DON stated that she did not get a call over the weekend about the incident. The DON stated that an investigation should have been started immediately and at the least, the accused person should have been removed from the schedule, pending results of the investigation, for the protection of all the residents.
415.4(b)(3)