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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: May 19, 2025
Citation Details Based on record review and interview conducted during the Recertification Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. This was evident during review of the Water Management Plan for Legionella. Specifically, the facility did not have a facility-specific water management plan for Legionella with mandatory components including but not limited to a description of the facility's water distribution system; temperature profile of the water system; control measures, and actions to be taken if control measures are not met. The findings are: The facility policy titled Legionella Water Management Program with a revised date of 06/13/2024 documented that the facility would maintain and monitor the facility's water system for Legionella. There was no documentation within the policy to indicate the document served as a site-specific water management plan for Legionella. Statements of prevention, surveillance, and reporting did not account for the actual design and operation of the facility's water system. The facility's Water Management Plan for Legionella had the following missing components: a description of the facility's water distribution system; temperature profile of the water system; facility-specific personnel roles and responsibilities; and control measures and actions to be taken if control measures not met. An environmental risk assessment form was not available for review. During an interview on 07/11/2024 at 1:50 PM, the Administrator stated they would ensure that the water management plan includes all the required components. 10 NYCRR 415. 19(a)(1-3) | Plan of Correction: ApprovedApril 15, 2025 Resident #2's 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 Promoting Resident 's Independence, Resident Rights and Abuse.??ÿ The Promoting Resident Rights and Independence Questionnaire,??ÿ 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: May 19, 2025
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 caused by the resident's comorbidity and brittle bones. They could not determine when the fracture occurred, and did determine the aide caused the skin tears. During an interview on 3/20/2025 at 3:59 PM, Nurse Practitioner #13 stated the facility determined the arm fracture was not caused by this incident, and they were unable to determine when it occurred but was due to brittle bones from comorbidities. Myelodysplasti[DIAGNOSES REDACTED] caused the bone density to be very thin and weak. It would not take much to fracture a bone. During an interview on 3/20/25 at 4:09 PM, Certified Nurse Aide #9 stated on 2/22/25 at about 5:00 PM, they went to provide incontinence care to Resident #2 by themselves. There were no issues at that time. The aide went to provide care at about 8:00 PM, and the resident's bed was wet with urine. The aide went to get help as the resident was 2-assist. When turning the resident in bed, both noticed a shoulder cut and told the supervisor. The aide stated they had provided care to the resident by themselves and should not have. The aide stated they reviewed each resident's care instructions daily. The aide did not remember the resident complaining of arm pain that night. 10 NYCRR 415. 12(h)(l) | Plan of Correction: ApprovedApril 15, 2025 Resident #1's care plan has been reviewed and was found to be accurate. There is a care plan intervention under Self ?ö?ç?ú Care Deficit??ÿ that states Allow 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 Self ?ö?ç?ú Care Deficit??ÿ that states Allow 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 Promoting Resident 's Independence, Resident Rights and Abuse.??ÿ The Promoting Resident Rights and Independence Questionnaire,??ÿ 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. |