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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the abbreviation survey (NY 359), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 was care planned for two staff for care, a staff member provided care alone, and the resident sustained [REDACTED]. Findings include: The 2/5/2024 facility policy Comprehensive Care Plan, documented residents and their representatives would play an active role in the implementation of the resident's care plan. The plan would address the resident's needs. Resident #2 had [DIAGNOSES REDACTED]. The 12/12/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, used a walker or wheelchair, was dependent for bed mobility/transfers/toileting, required moderate assistance with personal hygiene, was always incontinent of urine and occasionally incontinent of bowels, and received [MEDICAL CONDITION] medications and a diuretic (water pill). The 12/19/2024 comprehensive care plan documented the resident was at risk for falls, was at risk for impaired skin integrity, had the potential for excess bruising/bleeding, was incontinent of bowel and bladder, had accusatory behaviors, had [MEDICAL CONDITION], and had self-care deficits. Interventions included 2 staff at all times to act as witness, call bell in reach at all times, inspect skin every shift, maximal assistance with dressing, protect extremities during care, change/toilet with 2-staff assist every 2-3 hours, ensure gentle handling is provided at all times, dependent for transfers with mechanical lift, and dependent with bed mobility. The 2/24/2025 incident report documented an injury of unknown origin at 4:43 PM. Staff reported the resident had no recent falls and did not hit their elbow on anything. The resident reported falling although there were inconistencies noted in their report. An x-ray of the left upper arm was ordered due to reports of pain and swelling. The x-ray showed a left elbow fracture. The findings documented the resident had risk factors of bones breaking easily due to Myelodysplasti[DIAGNOSES REDACTED] that they felt caused the fracture. The family did not want the resident sent to the hospital for evaluation until the next morning. The report documented the facility did not find that abuse, neglect, or mistreatment had occurred. The following witness statements were included in the report: - Certified Nurse Aide #9's statement documented on 2/22/2025, the aide provided care at about 5:00 PM by themselves, held the resident by the shoulder and leg to turn them, and completed care. When attempting to provide care again at about 9:00 PM, the aide was unable to turn the resident in bed and obtained help from Certified Nurse Aide # 10. The staff noticed skin tears to the resident's left shoulder and elbow, which were not there previously. - Certified Nurse Aide #7's statement documented the resident had no pain or injuries on 2/22/2025 day shift. The next morning on day shift, the resident had pain in their left arm. The resident told the aide they had fallen out of bed and had a fight (arguement) with the person grabbing their arm the night before. The aide called the supervisor to report the pain. The aide's written report documented the resident had no skin tears on 2/21/ 2025. - Certified Nurse Aide #9 was called and reiterated the previous statement and stated the resident had not hit their head or elbow on anything. - Certified Nurse Aide #10 stated Certified Nurse Aide #9 asked for help as they could not turn Resident #2 on their own. The resident's shirt was already off, and the skin tears were evident with fresh blood. - The report documented the resident had inconsistencies with their version of events. The 2/22/2025 at 9:54 PM Registered Nurse #16 progress note documented the resident was turned to their left side in bed for incontinence care. When the resident was rolled back, staff noted a skin tear to the left shoulder and elbow with a scant amount of bleeding. Steri strips were applied, and the family and provider were made aware. The 2/23/2025 at 6:59 PM Registered Nurse #16 progress note documented the resident's left arm was assessed and the steri-strips were in place on the left shoulder and elbow. The elbow joint was red and warm to touch and swollen from elbow down. There were 3 separate areas of bruises on the left forearm. Staff were instructed the resident was 2-assist with care. The 2/24/25 Nurse Practitioner #12 progress note documented the resident was seen due to reports of left arm pain and swelling. There were no reported recent falls. X-rays and an ultrasound were ordered. The 2/25/2025 hospital discharge summary and left arm x-rays reports documented the resident stated they had fallen on 2/23/2025 and struck their head. The resident complained of head, neck, and left arm pain. The x-ray documented the resident had thin bones and an acute mild [MEDICAL CONDITION] elbow. A splint was placed. The 2/25/25 Nurse Practitioner #13 progress note documented the resident was evaluated due to mild left arm pain. An x-ray confirmed multiple fractures. There were questionable reports of the resident falling. The resident was to be sent to the hospital. The 2/26/25 Nurse Practitioner #12 progress note documented the resident returned from the hospital on [DATE] with a left arm splint due to a fracture. During an interview on 3/19/2025 at 3:00 PM, the Assistant Director of Nursing #3 stated resident specific care was documented in the care instructions and care plans. Staff were expected to follow those plans and instructions. Certified Nurse Aide #9 failed to follow the resident's plan of care by not having another staff member present during care. The reason the resident was to have 2 staff were due to false accusations in the past regarding staff. The facility believed the resident sustained [REDACTED]. The facility did not believe the arm fracture occurred at this time as they felt the fracture was due to brittle bones. The aide received disciplinary actions. During a telephone interview on 3/20/2025 at 1:03 PM, Certified Nurse Aide #7 stated staff were to follow resident specific care located in the care instructions, otherwise a resident could get hurt. Resident #2 was known to have falsely accused staff members of things in the past and therefore was 2-assist at all times. The resident did not complain of arm pain the day before. The resident told the aide that they got into a fight with staff, and they pulled the resident's arm. The aide stated they were not on duty at the time of the incident. During an interview on 3/20/2025 at 1:40 PM, Certified Nurse Aide #10 stated staff were to follow the resident specific care located in the care plans and care instructions. Resident #2 was to have 2 staff for all care and was very hard to turn in bed. Certified Nurse Aide #9 was attempting to provide care by themselves on 2/22/2025, was unable to do so, and called Certified Nurse Aide #10 for assistance. While turning the resident, the aides noted a skin tear on the resident's upper arm and shoulder. The supervisor was called, and the resident was assessed. There were no complaints of pain before, during, or after the supervisor's assessment. During an interview on 3/20/25 at 3:40 PM, the Director of Nursing stated the aides were expected to review each assigned resident's care instructions at the beginning of the shift. Staff were expected to follow those instructions. Certified Nurse Aide #9 did not follow the resident's care plan of 2 assist and was disciplined for that. The resident had an arm fracture, but the facility was unable to determine through the investigation as to when it occurred. The facility determined the fracture was | Plan of Correction: ApprovedApril 15, 2025 Resident #2s ADL care plan has been reviewed and was found to be accurate. All other residents care plans will be reviewed to ensure that they reflect the appropriate level of assistance required by the residents. The following policy will be reviewed and revised as deemed necessary to ensure that appropriate levels of assistance are care planned for all residents: Comprehensive Care Plan Policy Clinical Staff will be inserviced on the previously mentioned policy including any revisions and/or policy changes implemented after reviewing such policies. Staff will also be inserviced on ?ôPromoting Resident ?£s Independence, Resident Rights and Abuse.?Ø The ?ôPromoting Resident Rights and Independence Questionnaire,?Ø which will include components of the ADL Critical Element Pathway, will be conducted weekly and the results of the audits will be compiled and reported monthly to the QAA Committee. The audit will be completed monthly until we achieve 100% for three consecutive months. The Monitoring Log that is used to track Accidents and Incidents across the facility has been edited to include the names of staff members involved in each incident. This will allow for increased surveillance. The findings will be reported in QAA Monthly as part of the Investigation of Accidents/Incidents Audit that is completed by the ADON. The Director of Nursing will be responsible for overseeing this process. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY 983), the facility did not promote and facilitate the resident's right to self-determination through support of resident choice, including the resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 refused incontinence care and staff continued to provide care following multiple refusals. Findings include: The (MONTH) 2014 facility policy Notification of Rights, documented each resident would be provided with an environment allowing them to maintain dignity and quality of life. The 6/24/2014 Certified Nurse Aide Job Description documented to adhere to Resident's Rights regulation and promote resident's autonomy in decision making and honor their choice. Resident #1 had [DIAGNOSES REDACTED]. The 9/17/2023 Minimum Data Set assessment documented the resident had highly impaired hearing, had full cognition, required limited assist with most activities of daily living, required extensive assist of 1 with toilet use, used a walker, was occasionally incontinent of bowel and bladder, and received an antipsychotic, antidepressant, and an opioid. The 6/14/2023 updated comprehensive care plan documented the resident was incontinent of urine. Interventions included: incontinence briefs, the resident did not require assistance from staff, and preferred not to be disturbed on the night shift (11PM-7 AM) unless they rang for assistance. The 10/13/2023 incident report documented that at 6:40 AM, Certified Nurse Aide #4 continued to provide incontinence care despite the resident refusing and stating they were not incontinent. The resident stated the aide proceeded to roll the resident in bed and pull down their incontinence brief for incontinence care despite the resident stating they were not wet. Certified Nurse Aide #4's statement documented the resident had been incontinent at night the previous two nights and allowed care. The aide went into the room to check to see if the resident was incontinent, the resident stated to the aide that they were not wet, and the aide continued to provide incontinence care. The care plan was followed. The employee was suspended pending investigation and disciplinary actions were taken by the facility. The social worker followed up with the resident twice post incident and the resident had no psychological concerns. The 10/13/2023 at 3:37 PM Assistant Director of Nursing progress note documented the resident stated at about 6:40 AM, Certified Nurse Aide #4 rolled the resident in bed. The care plan was updated that the resident did not want to be woken at night unless they rang their call bell. On 3/20/2025 at 12:30 PM, Resident #1 was sitting in a chair in their room dressed and groomed. The resident reitterated the statement given in the incident report and that the resident was initially upset, then became angry. The resident did not see Certified Nurse Aide #4 following the incident. The resident stated the aide continued to provide care against their wishes, after the resident stated they did not need to be checked for incontinence. During an interview on 3/19/2025 at 3:00 PM, the Assistant Director of Nursing stated resident specific care was located in each resident's care instructions. Each staff member was expected to look at all assigned resident instructions at the beginning of the shift and before providing care to a resident. Staff members were expected to follow each resident's plan of care. All staff were aware of this, and they received education during orientation. One of the resident's rights was to be able to refuse care. If a resident refused something, staff were to make sure the resident was safe, exit the room, and report the refusal to a nurse or supervisor. Refusals were to be documented in the resident's medical record. A progress note was to be written by the nurse. On 10/13/2023, Certified Nurse Aide #4 went to toilet the resident. The aide's rational was that the resident was incontinent of urine the previous two times they provided care and the resident allowed the aide to provide the care. When the aide went into provide care to the resident, the resident stated they did not need incontinence care. The aide turned the resident over to provide care, and the resident began banging the wall with their hand to get help. Certified Nurse Aide #4 was suspended pending investigation and was given a written disciplinary action. The facility investigation determined Certified Nurse Aide #4 violated the resident's rights. There was no negative outcome to the resident or harmful intent. During an interview on 3/20/2025 at 2:52 PM, the Director of Social Services stated all residents were given a copy of Resident Rights and Choice on admission. Each resident had a right to refuse any care, treatment, medication, or staff. Staff were to reapproach and abide by the resident's choice. There was an incident where Resident #1 refused incontinence care during the night and the aide did not abide by those wishes. The director stated they interviewed the resident that morning and again after the incident. There were no negative effects, although the resident was angry about the situation at the time. During an interview on 3/20/25 at 3:40 PM, the Director of Nursing stated resident specific care was in their care instructions. The expectation was for staff to follow those instructions. If not, the staff member received disciplinary actions. All staff received abuse, neglect, and resident rights training on at least an annually basis. Each resident received education on resident's rights and choice upon admission. Staff were not to provide care to a resident who refused, although they should reapproach the resident after the initial refusal. The aide violated the resident's rights by not abiding by the refusal, but there was no abuse, neglect, or harm. The aide was suspended pending investigation, was reeducated, and later terminated for attendance issues. 10 NYCRR 415. 5(b)(1,3) | Plan of Correction: ApprovedApril 15, 2025 Resident #1s care plan has been reviewed and was found to be accurate. There is a care plan intervention under ?ôSelf ÔÇ£ Care Deficit?Ø that states ?ôAllow to make choices in care, i.e., clothing, ADL routine, etc. All other residents care plans will be audited to ensure that there is a care plan intervention under ?ôSelf ÔÇ£ Care Deficit?Ø that states ?ôAllow to make choices in care, i.e., clothing, ADL routine, etc. The following policies will be reviewed and revised as deemed necessary to ensure that residents choices and preferences regarding their care are carefully planned for as well as followed by the staff members when providing care: Comprehensive Care Plan Policy Resident Right to Refusal Policy Clinical Staff will be inserviced on the previously mentioned policies including any revisions and/or policy changes implemented after reviewing such policies. Staff will also be inserviced on ?ôPromoting Resident ?£s Independence, Resident Rights and Abuse.?Ø The ?ôPromoting Resident Rights and Independence Questionnaire,?Ø which will include components of the ADL Critical Element Pathway, will be conducted weekly and the results of the audits will be compiled and reported monthly to the QAA Committee. The audit will be completed monthly until we achieve 100% for three consecutive months. The Director of Nursing will be responsible for overseeing this process. |