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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 21, 2021
Corrected date: August 11, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 6/14/21-6/21/21, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were thoroughly investigated for 1 of 5 residents (Resident #250) reviewed. Specifically, Resident #250 had an injury of unknown origin which was not thoroughly investigated to rule out abuse and was not reported to the New York State Department of Health (NYSDOH) as required. This is evidenced by: The 8/2016 Nursing Home Incident Reporting Manual documents an injury of unknown source occurs when the source of the injury is not observed and if the resident is unable to report the cause, and the injury is suspicious due to the extent or location of the injury. To be reportable, the injury must be without known incident and the facility is unable to rule out abuse or care plan violations. The facility policy Freedom/Prevention of Abuse, Neglect, Exploitation, Involuntary Seclusion and Misappropriation of Property revised 9/2020 documents: - The facility will investigate and report all allegations of abusive conduct to include all injuries of unknown origin. - Reporting of alleged violations of abuse, misappropriation of funds, mistreatment, and neglect, including injuries of unknown origin and failure to follow the plan of care must be made to the administrator and in accordance with state law, to the Department of Health. These alleged violations should be reported as soon as possible, but not to exceed 24 hours upon having reasonable cause to believe that abuse, neglect, or mistreatment has occurred. - All incidents of potential abuse, neglect, or exploitation to include all injuries of unknown origin shall be investigated. The Administrator, Director of Nursing or Director of Investigations shall be responsible for the initial reporting, investigation and reporting of results to the proper authorities. Resident #250 was admitted to the facility with [DIAGNOSES REDACTED]. The 5/28/21 at 6:57 PM updated comprehensive care plan (CCP) documented the resident was at risk for falls. The resident had a fall out of bed on 4/17/21 and was found sitting on the floor in the middle of their room. The resident was assessed at the time of the fall and did not have injury. The 5/28/21 at 7:31 PM updated CCP documented the resident continued with dissipating facial bruising of the right and left eyes, with no swelling. Medical was made aware and ordered facial x-rays. The x-ray reported results were suspicious for a non-displaced nasal bone fracture with no other fractures seen and a CT (computed topography) was recommended. The 5/17/21 Incident/Accident Report documented the resident was found sitting on the floor in the middle of their room and no injury was noted at the time of the fall. The 5/17/21 Assistant Director of Nursing (ADON) progress note documented the resident had a recent fall with no injury and fall safety measures were in place. The 5/24/21 ADON progress note documented the resident had facial bruising involving the right eye area faded yellowish purple to left eye. The resident had a recent fall on their floor and the bruising could be consistent with the recent fall out of bed. The resident's family was notified. There was no documented evidence the injury of unknown origin was reported to the NYSDOH. The 5/24/21 Incident/Accident Reported completed by the ADON documented the ADON noted facial bruising on the resident to the right side of the face dissipating up to the right eye and left eye area. The report documented the following: - The 5/24/21 ADON statement documented they last saw the resident on 5/19/21, the resident had a fall on 5/17/21, and bruising was first noted by the ADON on 5/21/21. - The 5/26/21 staff statements from 2 certified nurse aides (CNA) and 2 temporary nurse aides (TNA) documented I don't know and did not include when the resident was last seen and if bruising was present. - The 5/27/21 CNA statement documented on 5/25/21 at 5:50 PM, the CNA brought the resident their dinner tray and noticed their left eye was bruised. - The report conclusion dated 5/27/21 by the ADON documented the resident was noted to have facial bruising to right facial side light purplish dissipating to left eye area fading purplish yellow green. The resident had dementia and poor safety awareness with a fall on 5/17/21 as well as bruising consistent with resident bumping their face on a bedside chair. - The typed Resident Incident with updates from 6/17/21 documented the resident had a fall on 5/17/21. On 5/24/21, a darkening purplish bruise was noted by a CNA with notification to the supervisor and to the DON. Based on staff statement and record review and internal investigation the facility has determined that the resident did not sustain an injury of unknown origin as defined by NYSDOH Regulation and Incident Reporting Manual. The report was not signed or dated. There was no documented evidence the facility thoroughly investigated the facial bruising that was noted by the ADON 4 days after the resident sustained [REDACTED]. The 5/25/21 nursing progress note documented the unit licensed practical nurse (LPN) requested the registered nurse (RN) look at the resident's face due to bruising. The resident's forehead had multiple stages of discoloration. The right eye had red/purple discoloration, the left eye had red/purple discoloration with [MEDICAL CONDITION] and was closed and appeared unable to open without assistance. The resident cried out when the other supervisor palpated the area. The resident had a fall on 5/17/21. The area lined up with the bedside chair on the window side of the room. On 6/14/21 at 11:10 AM, the resident was observed in a scoot chair near the nursing station and had faded bruises on the upper half of their face. During an interview on 6/15/21 at 9:29 AM, the resident's representative stated they had been notified that the resident had a fall, then days later they were notified that the resident had bruising. On 5/23/21, the representative had a video call with the resident at 3:00 PM. They could clearly see the resident's face which had no signs of bruising. Two days after the video call, the representative was called by the ADON to see if you were aware of the resident's facial bruising. The ADON told the representative the bruising was from the fall the week before. The ADON stated they were going to conduct an investigation and the representative was told the resident may have bumped their head on a stand near their bed. The following Saturday after being notified of the facial bruising, the representative had a video call with the resident. They stated the resident had black eyes and looked awful. The representative insisted the resident have an X-ray which was completed on 5/28/21 and was suspicious for a fractured nasal bone. During an interview on 6/18/21 at 10:26 AM, the ADON stated the RN on the shift was responsible for initiating an investigation. A bruise should have an individual investigation if it occurred days after a fall. The ADON stated the resident had two separate investigations for the 5/17/21 fall and the 5/24/21 bruise. The ADON recalled starting the investigation for the bruise. The resident's bruising was not seen for several days after their fall, an investigation was completed, and the family was included. The resident had a video call with their family the Sunday after the fall and before the bruising and the resident had no facial bruising at that time. The ADON was confident that the resident bumped their face on a chair in their room. The resident had a lot of bruising and the ADON thought the resident possibly broke their nose. The resident had facial X-rays which were suspicious for a fracture. When the ADON notified the resident's representative of the bruising, the ADON stated it could have been from the recent fall, and the representative said there was no facial bruising afterwards during the video call. All staff involved were interviewed, and the ADON and the DON (Director of Nursing) went into the resident's room and they determined the resident possibly bumped their face on the chair in their room. On 6/18/21 at 11:43 AM, the DON provided the Incident/Accident Reports for the resident. The reports did not include the typed report with the 6/17/21 updates or the statement that the resident did not sustain an injury of unknown origin. During an interview on 6/18/21 at 1:30 PM, the DON stated the RN on the shift was responsible for initiating an Accident/Incident Report and the investigation was reviewed as a team. The Nursing Home Reporting Manual was referenced to determine if an incident was reportable. Injuries of unknown origin were included in the Nursing Home Reporting Manual. A complete and thorough investigation was completed to determine if an incident met reporting guidelines. The DON or the Administrator were responsible for reporting, and the decision was made by the team the bruising was not reportable. The DON stated the Accident/Incident Report documented the bruising was first noted on 5/21/21 which was the Friday before the family's video call. The DON stated the family was not able to see the resident's bruising on the video call due to the resident's hair being in their face. The DON stated the report documented the resident had a dissipating bruise which had been there for a few days. The bruise did not come up for a couple of days following the resident's fall. The bruise was attributed to the resident's previous fall, so it was not an injury of unknown origin. The DON also stated that one of the staff statements documented the resident had erratic movements and tried to throw their legs out of the bed. 10NYCRR 415.4(b)(2)(3) | Plan of Correction: ApprovedSeptember 29, 2021 F610 Investigate/Prevent/Correct Alleged Violation What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #250 is no longer at the facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A review of all resident accident/incident reports in the past 30 days where injuries were sustained will be conducted to determine if a further investigation is needed to determine if abuse, neglect, or mistreatment occurred. Any A/I reports resulting in an injury of unknown origin where abuse cannot be ruled out will be reported to the New York State Department of Health (NYSDOH) according to the Incident Reporting Manual for Nursing Homes. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? The facility has implemented an accident/incident log for all incidents that result in an injury. All incidents logged will be audited weekly to ensure for a thorough investigation to include witness statements and thoroughly completed accident/incident reports to determine if abuse, neglect or mistreatment occurred. Nursing management including the Director of Investigations will be re-educated on the facility Abuse Prevention policy and procedure including investigating and reporting requirements of the NYSDOH Nursing Home Incident Reporting Manual. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The facility will audit all accident/incident reports that result in injury to ensure a thorough investigation is completed and ensure compliance with reporting requirements. This audit will be conducted weekly for 4 weeks and then monthly thereafter until determined otherwise by the QAPI Committee. The results will be reported to QAPI Committee for review. The Director of Investigations or designee will be responsible for oversight of the audits. Goal is 100% compliance with injuries of unknown origin to have an investigation for root cause and rule out resident abuse. In the event there is an injury of unknown origin without an investigation, the Director of Nursing will be notified immediately to conduct an investigation. Correction Date: (MONTH) 11, 2021 Overseen by: Director of Investigations |