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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: January 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (NY 765), the facility failed to ensure the residents' environment remained free of accident hazards for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1's care plan documented to remove the walker from their room when not in use. Subsequently, the resident fell from bed, their neck became entangled on the basket attached to their walker, and they were found without a pulse or respirations and expired. This resulted in Immediate Jeopardy past non-compliance, to Resident #1. Findings include: The facility policy, Accident/Incident Prevention and Risk Management, revised ,[DATE], documented each resident would receive adequate supervision and assistive devices to prevent accidents and the residents' environment would be managed to be free of accident hazards. Fall and elopement risk evaluations were completed within the electronic record upon admission, quarterly, annually and with any significant changes. The resident's care plan would be initiated and/or updated to reflect and address these and other injury risk factors with appropriate interventions as determined by the Interdisciplinary Team. The undated facility policy, Updating of Resident Care Plans, documented it was essential that each resident's care plan reflect the current status of the resident and the necessary interventions to meet their needs. Care plans were to be reviewed and updated regarding the resident's progress toward any stated goal. This was the responsibility of each member of the Interdisciplinary Team to complete before the meeting. Care Plans needed to be updated whenever the resident developed an acute illness or experiences another new event which could impact the resident's overall status: any updates should be reflected in the resident's Kardex (care instructions) for staff's immediate reference for care of the resident. The resident's Kardex would be considered part of the care plan. Resident #1 had [DIAGNOSES REDACTED]. The Comprehensive Care Plan documented: - On [DATE], the resident was at risk of falling and required partial/moderate assistance of 1 with a two-wheel walker, and the walker was to be left at the nursing station when the resident was not ambulating with staff. - On [DATE], the resident was dependent on 2 staff for transfers using a mechanical sit-to-stand lift. The resident had an ambulation program to walk to and from all meals and was dependent on 2 staff using a rolling walker, gait belt, and a wheelchair to follow. - On [DATE], the resident was non-ambulatory and dependent with assistance of one (1) staff for wheelchair mobility. The intervention to ambulate to all meals using a rolling walker was discontinued. The intervention to store the walker at the nursing station when not in use remained on the care plan. A [DATE] Occupational Therapist #7's evaluation and plan of treatment documented the resident was evaluated for a decline in ability to perform functional activities. They had a history of [REDACTED]. The resident had generalized weakness, deconditioning, decline in functioning, increased dependence on caregiver, pain, and cognitive deficits, resulting in the need for skilled occupational therapy. There was no documented evidence regarding the resident's current use of a walker. A [DATE] at 4:30 AM Incident Report completed by Registered Nurse Supervisor #2 documented the resident was found on the floor between the bed and the nightstand. The resident stated they were trying to get out of bed. They sustained a hematoma (collection of blood) to their forehead and an abrasion to the right knee. Predisposing environmental factors included furniture and poor lighting. There was no further documentation related to the furniture. There was no documented evidence the care plan was reviewed or revised with interventions to address environmental hazards. The [DATE] Physical Therapy Assistant #5 progress note documented they attempted ambulation with the resident. The resident stood with the rolling walker with moderate assistance of 3, the resident was leaning back and to the right. The undated Kardex documented the resident utilized a sit to stand mechanical lift with 2 staff assistance for transfers. The resident had a basket for their walker. The Kardex did not contain documentation the resident utilized a walker for transfers or ambulation or the intervention (from the care plan) the walker was to be stored at the nursing station when not in use. A [DATE] at 12:29 AM Licensed Practical Nurse #3 progress note documented the resident was in bed upon start of shift (night shift, 11:00 PM-7:00 AM) where they remained. The resident appeared to be resting comfortably in bed with all safety measures in place. A [DATE] at 1:04 AM Incident Report initiated by Registered Nurse Supervisor #2 documented they were called to the resident's room at 1:04 AM by Certified Nurse Aide #8. The resident was found between their bed and recliner with their neck on the wire basket of their walker, their right knee on the ground, and their left leg against the bed. The resident had no pulse and was not breathing. The resident was wearing non-skid socks and pressure relieving boots. The resident had a pressure mark on their neck, a skin tear on the left arm, bruising on their knees, and was incontinent of stool. The on-call nurse practitioner was called, who then notified the coroner and the local police, who in turn completed assessments on site. Predisposing factors included poor lighting, confusion, impaired memory, recent illness, and the resident ambulated without assistance. Certified Nurse Aide #1's statement documented they found the resident off their bed, with their neck caught on their walker basket. The Investigative Summary, unsigned and undated, documented the resident was care planned as dependent for transfers and bed mobility, was non-ambulatory, and their walker was to be stored at the nurse's station when not in use. On [DATE], the coroner contacted the facility and reported the resident had an active cardiac event at the time of their passing. The coroner concluded the resident's neck came to rest on the walker basket and the positional pressure on the carotid artery potentially contributed to their death. The cause of death was determined to be strangulation. During a telephone interview on [DATE] at 2:15 PM, Certified Nurse Aide #1 stated they were not aware the resident's walker should have been stored at the nursing station because it was not on the Kardex. They typically saw the walker in the resident's room at night when they worked. The night they found the resident, the walker was folded up and the wire basket attached to the walker was facing out (not against the wall). The walker was sandwiched between the bed and recliner. During a telephone interview on [DATE] at 9:26 AM, Coroner #4 stated when they arrived at the facility on [DATE] the resident was still warm and flaccid (limp). Based on autopsy, the resident was in the process of having a [MEDICAL CONDITION] that was a coronary dissection (tearing of a coronary artery). They could not say if the [MEDICAL CONDITION] happened first and then the resident fell on the walker or if the resident fell first and subsequently had a [MEDICAL CONDITION]. The imprint on the neck from the walker basket was very evident. They stated the resident did not fall from a high distance to cause the mark; the mark was more from pressure. They presumed strangulation was the immediate cause of death and the contributing factor was the [MEDICAL CONDITION]. During a telephone interview on [DATE] at 9:30 AM, Registered Nurse Supervisor #2 stated the resident attempted to get out of bed unassisted and transferred on their own in the past. They were not sure why the resident had a walker in their room and stated the resident worked with therapy with the walker. The resident was dependent for transfers. During an interview on [DATE] at 10:38 AM, the Director of Nursing stated it was best practice to check the Kardex at the time of the care plan review. The Nurse Manager was responsible for completing the care plan review at the time the Minimum Data Set assessment was scheduled. If nursing staff added a new intervention to the care plan, they were responsible for ensuring the intervention was transferred to the Kardex. There was no second check process to ensure interventions were carried over the to the Kardex. During a telephone interview on [DATE] at 3:33 PM, Occupational Therapist #7 stated prior to the resident's hospitalization , they implemented an ambulation program for the resident using a rolling walker. When the resident returned from the hospital on [DATE], they could no longer ambulate. Occupational Therapist #7 stated they discontinued the ambulation goal because they did not want staff ambulating the resident. Occupational Therapist #7 stated they typically notified as many staff as they could upon discontinuing a goal and they could not recall who they spoke with. There was no process in place to determine who was responsible for removing the resident's walker once a goal was discontinued. They were not aware the walker was not removed from the resident's room. They used a walker from the therapy department on [DATE] and did not use the walker in the resident's room. During an interview on [DATE] at 4:15 PM, Licensed Practical Nurse Manager #6 stated they were responsible for initiating, updating, and reviewing care plans. When there was an incident and the Interdisciplinary Team made recommendations, the Licensed Practical Nurse Manager added those to care plans. At the quarterly Care Conferences from ,[DATE] to ,[DATE], they did not compare the Care Plan against the Kardex. When adding interventions to the Kardex, they needed to choose a category (like safety or elimination); if that step was left out, the intervention would not transfer to the Kardex, and the system did not alert anyone the transfer failed. Licensed Practical Nurse Manager #6 stated near the end of their stay, the resident no longer ambulated with staff but continued to ambulate with therapy. They stated the walker should have been removed from the resident's room when the ambulation goal was discontinued in (MONTH) 2024. The resident's Care Conference Attendance Sheets documented Licensed Practical Nurse Manager #6 signed they were in attendance on [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 1:10 PM, the Administrator stated they determined there was a care plan violation on [DATE] when the Interdisciplinary Team reviewed the incident and found the Kardex did not match the Care Plan. The care plan violation contributed to the incident. They were not aware Licensed Practical Nurse Manager #6 was not comparing the Care Plan against the Kardex prior to the incident, as they were expected to. During a telephone interview on [DATE] at 1:03 PM, the Medical Director stated they expected the Care Plan and Kardex to match so the certified nurse aides were aware of interventions. They stated the walker should have been removed from the resident's room when staff were no longer using it. The Medical Director stated the resident died from strangulation. -------------------------------------------------------------------------------------- Immediate Jeopardy past non-compliance was identified, and the Administrator notified on [DATE] at 1:58 PM. The facility provided verification the following corrective actions were completed: - On [DATE], Licensed Practical Nurse Manager #6 was retrained on Updating Resident Care Plans. - On [DATE], all licensed nursing staff were retrained on Updating Resident Care Plans. - On [DATE], staff education sign in sheets were reviewed and compared to current staff list and no discrepancies were identified. - All resident Care Plans/Kardex's were audited on [DATE] to ensure all interventions were accounted for. The Director of Nursing continued to audit five resident records weekly to ensure compliance. 10NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedFebruary 12, 2025 A plan of correction is not required for past non-compliance deficiencies. The facility remains responsible via continued implementation of the corrective actions developed by the facility or subsequent revisions to that plan of correction to ensure ongoing compliance. |