NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2021
Corrected date: October 6, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY 214) conducted on [DATE], the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, - Resident #3 had an unwitnessed fall and neurological checks were not completed as documented. The resident was found expired 2 hours after the last documented neurological check in full rigor mortis (postmortem rigidity, approximately ,[DATE] hours to set in). - Resident #3 refused a skin assessment upon admission and a follow-up skin assessment was not completed. The resident later expired at the facility and when the autopsy was done, the residnet was found with a pressure ulcer on the left hip that was not assessed, monitored, or treated while at the facility. Findings include: The ,[DATE] Neurological Check Policy documented it was the facility policy to perform neurological checks per policy unless otherwise ordered by a physician or designee. Neurological checks will be performed per protocol for all head injuries or falls in which the resident has or may have struck their head. Once neurological checks are initiated, the following protocol/schedule will be used: every 15 minutes x 4; every 30 minutes x 2; every hour x 4; every 4 hours x 24; and or as ordered by the physician. The ,[DATE] Skin/Pressure Injury Prevention & Intervention Program documents: 1) The resident will be assessed for skin/pressure injury prevention/intervention in conjunction with completion of the Risk Assessment Form (Braden) and resident assessment. 2) The Risk Assessment will be completed by a registered nurse (RN) on Admission/Re-Admission and every week x 4 weeks after. Quarterly, Annually, significant Change and upon the identification of a new pressure injury. 3) Based on the resident assessment and evaluation process and individualized comprehensive care plan will be developed including all involved disciplines. a. Residents at risk for skin/pressure injuries will have a preventative plan implemented. b. Residents with skin/pressure injuries will have a preventative plan implemented. 4) Weekly skin evaluations will be done on every resident. 5) Residents with new skin/pressure injuries will be referred to the dietician for nutritional assessment with special attention given to malnutrition, weight loss and hydration. 6) The practitioner will be notified if a new skin/pressure injury develops and the practitioner's response including treatment ordered will be documented in the nursing notes. 7) Weekly interdisciplinary team (IDT) meetings will be held to review/discuss all residents with pressure injuries, including review of weekly wound sheets, turning and positioning schedules, treatment records and weekly skin checks. Resident #3 had [DIAGNOSES REDACTED]. The [DATE] Admission Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired and they required extensive assist for most activities of daily living (ADL). The resident had no skin impairments and had an order for [REDACTED]. Neurological Checks: The [DATE] at 11:15 PM registered nurse (RN) #2's progress note (entered into the record on [DATE] at 5:17 AM), documented the resident had a fall in their room and was found on the right side of the bed with no apparent injury. They were at their baseline mental status and in no pain. Nursing interventions included the resident would be oriented to surroundings and assigned staff, neurological checks initiated, call bell and personal items within reach, low bed, and frequent toileting. The resident's contact did not answer the phone when called. The resident was put back to bed with a Hoyer lift (mechanical lift). The [DATE] at 11:15 PM, RN #2's progress note (entered into the record on [DATE] at 5:19 AM) documented the nurse practitioner (NP) was notified of the resident's fall at 12 AM and requested to monitor vital signs. The [DATE] at 11:15 PM, Accident and Injury report completed by RN #2 documented the resident had an unobserved fall on the right side of the bed and the bed was in low position. The resident was assessed; range of motion was normal, and no injury was found. The resident refused vital signs, told the nurse to leave them alone and they were transferred back to bed. The NP was notified, and a family member did not pick up the phone when called. Interventions in place at the time of the fall included a low bed with mat, call bell within reach, and proper lighting. Procedures to prevent recurrence included a medication review was needed. Neurological checks were implemented. Neurological check forms, completed by RN #2, attached to the [DATE] Accident and Injury report documented: - Neurological checks were started at 12:15 AM and were completed every ,[DATE] hour through 3 AM, then every 1 hour at 4 AM, 5 AM, and 6 AM. - RN #2 documented they checked the resident's level of consciousness, speech, and motor response. The pupil size and reaction was left blank. The [DATE] at 5 AM, Care Record, completed by certified nurse aide (CNA) #3 documented care was provided to the resident that included 2-assistance with incontinence care, bed mobility, and dressing. The [DATE] at 5 AM, Medication Administration Record [REDACTED]. The [DATE] at 5 AM, Vital Sign report, completed by RN #2 documented 2 sets of results: - pulse oximetry 95%, pulse 70, respirations 18, temperature 96.8; and - pulse oximetry 96%, pulse 72, respirations 18, temperature 97.0. The [DATE] at 6:40 AM, RN #2's progress note (entered into the record on [DATE] at 10:38 AM), documented the resident had a fall earlier in the shift with no injury noted. They were alert and able to make their needs known, neurological checks were within normal limits, and they continued to refuse vital signs after redirection. The resident was resting in bed with no complaints voiced and the team would continue to monitor. The [DATE] at 8:15 AM, respiratory therapist (RT) #1's progress note documented they were called to the room to assist with CPR. The resident was hooked up to an Ambu bag (artificial manual breathing unit) and to oxygen, and they assisted with chest compressions and providing breaths. RT #1 stayed in room until emergency medical services (EMS) arrived, and EMS called the time of death for resident. RT #1 exited the resident's room at 8:29 AM. The [DATE] at 9 AM, nursing progress note documented the resident was found by staff at 8:15 AM with no pulse, no respirations, and no blood pressure. Staff began CPR as well as the defibrillator and called 911 immediately. Oxygen was in place and CPR continued until paramedics arrived at 8:28 AM. The resident was pronounced deceased at 8:38 AM. The resident's family was made aware and supports were in place. The [DATE] EMS report, completed by emergency medical technician (EMT) #14 documented they arrived at the resident's room at 8:28 AM and the resident was found on the floor with CPR in progress. The resident had obvious signs of death; arms were fully extended and stiff. There was lividity (gravitational pooling of blood in dependent parts of body) and the resident was found at room temperature. There were no signs of trauma or signs of suspicious death. Per staff, the resident was last seen at approximately 5 AM and was fine. Staff reported on arrival, even though the resident was obviously deceased with full rigor mortis, they could not pronounce the resident's death. The [DATE] at 12:59 PM, preliminary Autopsy Report, completed by Medical Examiner #9 documented the resident had a reported fall on [DATE], was found unresponsive in bed on [DATE] and pronounced dead after resuscitative efforts. There was no sign of traumatic injury. The autopsy disclosed a focus of acute pneumonia and they were still awaiting culture and toxicology studies. The [DATE] final Autopsy Report, completed by Medical Examiner #9 documented the resident's final [DIAGNOSES REDACTED]. On [DATE] at 2:20 PM, RN #4 Manager stated in an interview, when a resident had an unwitnessed fall, they expected an Accident and Injury report to be started, neurological checks implemented, and the physician/family notified. CNAs should be rounding on residents every hour to check that they had not fallen or needed to be toileted. On [DATE] at 10:39 AM, RT #1 stated in a telephone interview, they responded to the resident's Code Blue (indicates an emergency) on [DATE] and assisted with bagging and chest compression on the resident. The resident has signs of rigor mortis and performing chest compressions was difficult. They recalled the resident's arms were stiff at their side. They worked on the resident for 15 minutes when EMS arrived, and EMS called the code. On [DATE] at 7:35 AM, RN #2 stated in a telephone interview, they were in and out of the resident's room through the shift after the resident's fall on [DATE]. They were the only nurse on duty that shift and also had to care for several other residents with high care needs. They were not able to document neurological checks in the medical record at the time they were completed and instead documented the neurological checks on a piece of paper they kept in their pocket to enter into the medical record later. They last saw the resident around 6:40 AM and they were moving around, verbalizing, and refused vital signs. RN #2 stated the facility tried to tell them the resident had rigor mortis when found and RN #2 believed that was not possible as they saw the resident alive at 6:40 AM. On [DATE] at 10:43 AM, CNA #3 stated in a telephone interview, they worked the 11 PM to 7 AM shift on [DATE] and was assigned to the resident. CNAs were required to round on residents 3 times nightly to see if they needed assistance with incontinence or to see if they had fallen. The resident required extensive assistance from 2 people for toileting and they toileted the resident along with another CNA around 12 AM, 2:30 AM, and 5:30 AM. Around 5:30 AM, they went into the resident's room and saw RN #2 assisting the resident. They recalled the resident was always stiff and they could barely bend the resident's arms. On [DATE] at 10:36 AM, the Director of Nursing (DON) stated in a telephone interview, they came on duty after the resident expired on [DATE]. They talked to RN #2 and CNA #3 about the events of the night. The DON was told the resident fell without injury and RN #2 and CNA #3 reported care was provided overnight. RN #2 reported the last time they saw the resident was between 6 AM and 6:40 AM. RN #2 was the Supervisor that night and was also assigned to the medication cart. RN #2 told them they had done all the neurological checks on paper and forgot to enter them into the medical record before they left their shift. RN #2 returned to the facility after their shift ended and documented the neurological checks in the medical record. The DON stated they observed RN #2 take a piece of paper from their pocket and used that paper when documenting the neurological checks in the medical record. The DON did not see the resident's body or the EMS report that documented the resident had rigor mortis. The facility protocol for full code residents was to start chest compression when there was absence of pulse/respirations. Once EMS or the physician arrived on scene, they were responsible to call the time of death. On [DATE] at 1:38 PM, Medical Examiner #9 stated in a telephone interview, they performed the resident's autopsy on [DATE] at 12:59 PM. They were not on scene at the facility on [DATE] when the resident expired. They stated the resident was diagnosed with [REDACTED]. They were aware the resident fell the evening of [DATE] around 11:15 PM and facility staff put the resident back to bed and found them later deceased . There was no trauma found during the autopsy. Pneumonia was found in one of the resident's lungs along with pus in the trachea and larynx. A culture showed [DIAGNOSES REDACTED] Pneumonia which could cause death in someone as frail and weak as the resident. The resident's pneumonia had not yet consolidated, and they believed they had pneumonia present approximately ,[DATE] days before death. When they examined the resident's body 28 hours after the facility found the resident deceased , there was no signs of rigor mortis left. Rigor mortis could take 2 hours to start, and very warm temperatures could speed up the rigor mortis process. The resident's [DIAGNOSES REDACTED]. The resident had fixed lividity on autopsy and that usually occurred about 36 hours after death. Medical Examiner #9 stated they suspected the resident had been deceased longer than 36 hours and they probably died in the middle of the night. On [DATE] at 1:52 PM, funeral director #1 stated in a telephone interview, they observed the resident upon arrival at the funeral home on [DATE] in full rigor mortis with arms extended out straight over their head. Their face was deep purple and from their expertise, had been deceased for quite some time, and believed the resident expired around midnight. Funeral director #1 stated the resident was not in a condition of someone that expired at 8:30 AM that day. On [DATE] at 9:43 AM, funeral director #2 stated in a telephone interview, they arrived to the facility around 10 AM to 10:30 AM on [DATE] and went to the resident's room. They observed the resident on the bed with their arms in the air. They had not witnessed that positioning with rigor mortis before and not they were not sure what could have caused it. They stated rigor mortis typically occurred within 4 to 8 hours, but could be sped up by high temperatures. Funeral director #2 was not aware of any medical conditions or [DIAGNOSES REDACTED]. On [DATE] at 10:15 AM, CNA #12 stated on in a telephone interview, they came on duty on [DATE] at 7 AM, they began rounds and got to the resident's room around 7:45 AM to 8 AM. They observed the resident face up in bed, wearing a hospital gown, with their hands in the air like they were reaching for something. The resident was not responsive, so they notified the licensed practical nurse (LPN) who responded to the room. They did not go back to the room after that. On [DATE] at 11:15 AM, EMT #14 stated in a telephone interview,they arrived at the resident's room on [DATE] at 8:28 AM. A nurse they assumed was the Supervisor, approached them and apologized they had to respond to the facility. The nurse stated the resident was obviously deceased , but facility policy required them to perform CPR until a physician or EMS pronounced the death. Upon entering the room, facility staff were performing CPR on the resident. The resident was lying on their back with arms extended outwards at nearly a 90-degree angle. They instructed staff to stop CPR and EMT #14 pronounced the resident deceased . The resident was very stiff with obvious signs of rigor mortis. Rigor mortis typically took 6 hours to occur and for rigor mortis to be that pronounced, in their clinical opinion, it could have been longer than 6 hours since death occurred. When they inquired about the last well check on the resident, the Supervisor told them the resident was documented as fine at 5 AM. EMT #14 stated they felt the nurse's statement of the resident being well at 5 AM was inconsistent with how the resident presented. They stated they were not familiar with conditions that could speed up the rigor mortis process. On [DATE] at 7:49 AM, a re-interview with RN #2 was attempted and RN #2 refused to answer any questions or explain how they provided care to the resident when the Medical Examiner, funeral directors, and EMT provided accounts that the resident expired in the middle of the night. On [DATE] at 8:16 AM, CNA #3 was re-interviewed and refused to answer or explain how they provided care to the resident when the Medical Examiner, funeral directors and EMT provided statements the resident expired in the middle of the night. On [DATE] at 12:58 PM, physician #27 stated in a telephone interview, they were a part-time physician at the facility and saw the resident once for the History and Physical. They stated rigor mortis was rigidity that presented a few hours after death though they were not sure the specific time for rigor mortis to occur. [DIAGNOSES REDACTED] and catatonia would not cause rigor mortis to be sped up. They were not aware the resident expired and not aware they were found deceased with rigor mortis. Skin Assessments: The [DATE] at 3:01 PM registered nurse (RN) #25's progress note documented the resident was combative upon admission and they refused admission vital signs and assessment. There was no documentation in the record the resident was reapproached for an admission assessment. The [DATE] Braden (skin) Assessment documented the resident was at moderate risk for pressure sores. The [DATE] comprehensive care plan (CCP) documented the resident was at risk for impairment of skin integrity. Interventions included turn and position every 2 hours; skin care every shift, and weekly skin checks. The CCP did not document the resident had actual skin impairment. The resident's medical record did not document weekly skin checks were done as documented in the CCP. The undated Kardex (care instructions) documented the resident was dependent on 2 staff for bed mobility, transfers and toileting. They were incontinent of bowel and bladder, wore briefs, and barrier cream was to be applied to the buttocks every shift. The [DATE] nurse practitioner's (NP) progress note documented nursing asked for an evaluation of the resident's high dose medications. The resident was alert, awake and currently laying in bed and appeared thin and frail. The resident's skin was warm and dry and without rashes or [MEDICAL CONDITION]. The note did not document the resident had skin impairment The [DATE] History and Physical, completed by physician #27, documented the resident was admitted with failure to thrive, catatonic disorder, and recent recurrent poor oral intake. The resident refused to talk to them and told them to leave. When asked if they could examine them, they stated no and closed their eyes and refused to open. The resident was lying in bed in no acute distress. The assessment documented was refusal of care by resident, dementia, unable to determine as resident refused to speak, and anxiety, continue [MEDICATION NAME] (anti-anxiety medication). The resident's [DATE] through [DATE] physician's orders did not document any treatments for impaired skin or a pressure ulcer. The [DATE] through [DATE] nursing notes did not document the resident had skin impairment. The [DATE] at 3:22 PM, Director of Social Services progress note documented a family meeting with department updates. Per nursing, the resident had no wounds or skin tears. The [DATE] registered dietitian (RD) #16's assessment completed on [DATE] documented the resident's weights prior to admission were not available and they refused weights at the facility. The resident's intakes fluctuated and they had no skin impairments. The [DATE] at 9 AM, nursing progress note documented the resident was found by staff at 8:15 AM with no pulse, no respirations, and no BP. Staff began cardiopulmonary resuscitation (CPR) and 911 was called immediately. The resident was pronounced dead at 8:38 AM. The [DATE] at 12:59 PM Medical Examiner's Report, completed by Medical Examiner #9 documented during the autopsy it was noted there was a decubitus (pressure ulcer) bandage labeled [DATE] (admitted to facility on [DATE]) on the left lateral hip/buttock region. On removal, a less than ,[DATE]-inch superficial pressure ulcer was noted with some surrounding darkened skin. On [DATE], Medical Examiner #9 stated in an interview, on [DATE], they completed the resident's autopsy, and they found a bandage on the resident's bottom dated [DATE]. Under the bandage was a superficial ,[DATE]-inch pressure ulcer. Pictures were taken of the bandage and the pressure ulcer. On [DATE] at 4:56 PM, the Administrator stated in an email there were no weekly skin checks or wound notes found for the resident. On [DATE] at 10:50 AM, dietetic technician (DT) #15 stated in an interview, they became aware of resident skin issues by checking the clinic information because the clinic was responsible for the admission skin inspection. They were not aware the resident had a pressure ulcer and if they had known they would have notified the RD who would have assessed the resident immediately as pressure ulcers were considered high risk and further nutritional interventions might have been needed. On [DATE] at 11:15 AM, RD #16 stated in an interview, the resident had no skin issues that they were aware of. On [DATE] at 11:49 AM, trainee nurse aide (TNA) #21 stated in an interview, the resident was incontinent and required assistance with care, though the resident could independently role side to side. They stated they did not recall seeing a bandage on the resident's skin during incontinence care. On [DATE] at 1:30 PM, certified nurse aide (CNA) #23 stated in an interview, the resident wore briefs and they provided incontinence care on their shift. They did not recall seeing a bandage on the resident's skin during care. On [DATE] at 2:05 PM, RN #25 stated in an interview, they were the clinic RN and performed all of the admissions and that included a head-to-toe assessment. If a resident refused the assessment, they would pass the information on to the Supervisor. On [DATE], they did the resident's admission intake. The resident kicked and swung during the assessment and refused all assessment. They notified RN Manager #4 the resident refused the admission assessment. On [DATE] at 11:05 AM and 11:35 AM, the Assistant Director of Nursing (ADON) stated in an interview, they were covering on the resident's unit and completed the daily notes required by insurance. On admission, the admission nurse completed the head-to-toe assessment and when a resident refused, the staff should reapproach to complete the assessment. They were not sure if the resident refused the assessment when admitted . The resident was incontinent and required assistance with toileting. No one notified them the resident had a bandage or a skin issue. The ADON stated weekly skin checks were part of the CCP, however the unit was currently not doing weekly skin checks and they were working on doing them. On [DATE] at 2:22 PM, autopsy pictures were reviewed and showed a large, bordered dressing located on the resident's left hip. Documented on the dressing were initials and the date [DATE]. Pictures of the uncovered wound showed a small superficial pressure ulcer. On [DATE] at 9:47 AM, physician #28 stated in a telephone interview, they believed the wound team reviewed every new admission for skin integrity. Physician #28 also looked at residents' skin during the History and Physical and if they refused the assessment, they would tell nursing to complete the skin assessment when the resident was in a better mood. Sometimes they would also ask the nurse practitioner (NP) to follow up. The resident was very difficult, resistive to care, and very angry. They expected to be notified of continued skin assessment refusals and were not sure if they, the NP or other physicians were notified of the refusal. They were not aware the resident had a pressure ulcer. On [DATE] at 10:39 AM, RN #4 Manager stated in a telephone interview, residents had a head to toe assessments upon admission. If refused, the NP or physician would eventually see their skin for the admission History and Physical. They were not aware the resident refused the admission assessment. Weekly skin checks were done during the shower with the licensed practical nurse (LPN) and CNA. They stated skin checks did not always get done and when the resident went 14 days without having their skin looked at, it was not done timely. They stated none of the CNAs notified them of skin issues over the time the resident resided at the facility. They were not aware the resident was admitted with a pressure ulcer bandage. If staff saw the bandage during care, they expected to be notified and were not. The family or Healthcare Proxy (HCP) should have been notified the resident was refusing the admission assessment and they were not sure if they were. 10NYCRR 415.12 | Plan of Correction: ApprovedSeptember 8, 2021 F684 Quality of Care What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #3 no longer resides 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? Residents receiving neurological checks will be audited to ensure checks are completed per policy and documented accurately. Residents who are refusing skin assessments will be re-approached and if continue to refuse the skin assessment, medical and responsible party will be notified. 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 will re in-service all licensed nursing staff on the Neurological Check Policy to ensure checks are done per policy and documented accurately. The facility will re in-service the RN admission nurse, RN managers/supervisors and RN wound nurse on the skin assessment policy and what to do if resident refuses. Continued resident refusals of skin assessments despite re-approach will be reported to medical provider and responsible party. 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 10 residents per week to ensure neuro checks and skin assessments are completed per policy. Also, if the skin assessments are not able to be completed after resident has been re approached, both medical and responsible party will be notified. This audit will be conducted weekly for 4 weeks with a target threshold of 90%. The results of the audits will be reported to the QAPI committee to determine if further auditing is needed. Correction Date: (MONTH) 6, 2021 Overseen by: Assistant Director of Nursing |