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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 8, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. Specifically multiple observations were made of resident rooms were observed with wood furniture scratched veneer, missing key holes, missing handles to dressers or wall cabinets, bedside tables were observed with missing paint on the lower leg areas. 2. ) resident rooms were observed with mismatched paint, holes in dry wall and duct tape on the floor, missing tile and/or grimy tile. 3. ) resident's wheelchair was observed with torn cushion and enteral feeding pumps and poles on 2 East and 2 West unit was observed with cream-colored stains on the pump and pole bottoms. 4). the whirlpool tub was noted to be dirty with discarded items inside and unit shared bathrooms were observed with discolored damaged or missing tiles. 4. ) the step leading to the trash dumpster was noted to be rusty with hole in metal stairs on the left side of the steps. 5). the wall behind in the 2nd floor dining room refrigerator and false pantry was observed with holes in back wall area. This was evident in 5 out of 6 units observed (2 East, 2 West, 3 East, 3 West and 4 West). The findings are: The facility's policy titled Cleaning and Disinfecting Resident Care Items and Equipment reviewed (MONTH) 2024 documented resident shared equipment including shared items and durable medical equipment shall be cleaned and disinfected according to the current Centers of Disease Control recommendations for disinfection and the Occupational Safety Health Administration Bloodborne Pathogens Standard. Durable medical equipment such as enteral feeding pumps, intravenous poles shall be cleaned after usage on the Environment Protection Agency registered antimicrobial list recommended by public health authorities. Medical storage equipment such as medication/treatment carts, cardiopulmonary resuscitation carts shall be cleaned when visibly soiled and on as needed basis. The facility policy titled 7 Step Cleaning Progress reviewed (MONTH) 2024 documented rooms the policy is to establish an efficient cleaning process and maintain a sanitary physical environment. Rooms will be cleaned thoroughly cleaned monthly or as needed. The following was observed during multiple observations conducted from 12/12/2024 to 12/19/ 2024. a.) Kitchen observations on 12/12/2024 from 09:21 AM - 10:58 AM, 12/16/2024 at 04:29 PM and 12/18/24 01:13 PM, include leaking kitchen kettle, cracked tile on the floor and missing tile. There is a gap in the wall edge by refrigerator #3 by wall mixer, cracked tile around the drain by the kettle and prep area, cracked tile by the stove partially replaced. The metal shelf of the kitchen holding washed dishes has grease residue on the metal shelves. Cracked corners on the resident fiberglass meal trays. Cracked floor and baseboard tiles in the dish room. Cracked floor tile under freezer # 2. Cracked tile by prep station thawing sink opposite refrigerator # 1. Visible hole under the sink pipe in the kitchen dish room. During an interview on 12/17/2024 at 11:28 AM, Dietary Aide # 7 stated, the kitchen tiles have been broken and maintenance comes to fix them when water comes up from floor drain areas. During an interview on 12/17/2024 at 10:32 AM, Dietary Aide # 4 stated, the leaking cooking kettle makes a puddle on the floor. There was a puddle in the kitchen at least 1-time last week after it rained heavy, and maintenance came to take care of it. b). On 12/17/24 at 10:29 AM, during kitchen trash disposal task with Dietary Aide # 4 the metal walking stairs leading to the bottom of the facility trash compactor were observed to be damaged. There was stored wheelchair parts visible under stairs area. On 12/19/2024 at 12:44 PM main floor staff dining lounge past the kitchen on lobby floor noted with black colored droppings under sink, food stain in freezer and bottom drawer noted with light brown colored food stain on the bottom of the lower drawers. c.)2nd Floor shared dining room by the elevator was observed from 12/12/2024 to 12/19/2024 with no radiator cover, metal exposed under mounted wall television area and the ice machine vent was dusty. There was a noticeable hole in the wall behind the refrigerator with a gap in between the refrigerator and the false pantry. 2nd Floor -2 East unit - on 12/12/2024 at 3:09PM and 12/17/2024 at 03:14PM, 12/17/2024 at 3:35PM - 3:37PM, the following was observed room [ROOM NUMBER]E-209 enteral feeding pump with dried cream-colored stains back of the pump. room [ROOM NUMBER]E - 206 has 6 strip of duct tape on floor holding tile down. The trash can by A bed is covered with a brown colored stain on the outside. 2 East- fan by room [ROOM NUMBER]E-222 noted to be dusty and has a white ribbon inside the fan and stamped with sticker inspected 8/20/ 2024. Metal fan by room [ROOM NUMBER]E-211 and 2E-215 dusty on outside with stamped inspected 7/16/ 2024. 2nd Floor on 12/12/2024 at 12/12/2024 at 04:46 PM, 12/17/2024 at 03:14 PM and 12/17/2024 at 03:40 PM, Elevator # 1- left and right lower edge damage to dry wall. Elevator # 2nd number elevator left lower edge and right side exposing dry wall covered with duct tape. Elevator # 3 has damage to dry wall on the 1/3 on left and ??®?? right side. 2 East -room [ROOM NUMBER] - 4 pieces of black duct tape holding floor tiles. 2 East shower room [ROOM NUMBER]/17/24 03:17 PM to 03:20PM, there was a gap in tile under sink in shower opposite nurses' station in 3 areas, shower drain with brown colored debris around hole in the drain cover. Large shower chair with rusty wheels. Large bathtub was dusty. The large bathtub contained the following a gray colored commode, pair of discarded vinyl gloves, empty bucket, brown colored debris on tub jets. Hoyer canvas blue wrap by the arms trap areas noted to be dusty on the fabric. d.) 2 West unit - room [ROOM NUMBER] P - on 12/12/2024 02:45 PM, 12/16/2024 at 10:38 AM and 12/17/2024 at 03:00 PM, the call light box on the wall was noted hanging from the wall over the resident's headboard on 12/12/ 2024. ) On 12/12/2024 at 02:49 PM, 12/16/2024 at 02:53 PM, 12/17/2024 02:57 PM and 12/18/2024 07:57 AM, room [ROOM NUMBER] P enteral feeding pump noted with cream-colored stains on the pump back area and pole noted with cream-colored stains on the bottom of the pole and the resident's floor. Air conditioning/heater unit damaged on left side by window bottom, unit is dusty with grey colored dust, dried leaves in adjustment knob. On 12/12/24 02:58 PM, 12/13/24 09:35 AM, the following was observed. room [ROOM NUMBER] wall divider by sink with chipped wood and air conditioning/heater unit dusty and unit crash cart with dusty bottom area. Medication Cart in the nurse's station observed with dust. room [ROOM NUMBER] enteral feeding pole with cream colored feeding on bottom dried and on enteral feeding pump front and back area. Air conditioning/heater unit dried leaves, gray colored dust in vent area. 2 West bathroom- tub with stains in tub, plastic cup on right side of seat, white towel, belt with white colored dust, shower chair for larger residents with brown colored stain on bottom area, cracked tile under sink on left edge approximately 1 ??®??Ñ x ??®??ó inch. Bottom wheels for larger shower chair with rust on all 6 wheels. Wound Care treatment cart for 2 West on - 12/18/24 09:41 AM empty sharps container noted with cream colored tape affixed to the right side of the sharps container holder horizontally to keep it closed. Environment 2 West- 12/12/24 11:46 AM 2 West Hoyer lift dusty plastic foot pad and missing paint on both Hoyer leg area. 2 West Medication room on 12/16/2024 at 10:05 AM veneer on cabinet door labeled pill crusher and thermometer had ripped veneer on upper cabinet middle left door. During an interview on 12/18/2024 at 08:29 AM, the Housekeeper #1 stated, when they clean the bedside table, they scrape down the table and mop it to get the floor clean. They are not sure who they report to if the table bottom is crusty or missing paint. This is where the residents eat, and residents put their feet on, and you want it to be comfortable. e.) 3rd East and 3 West units were observed from 12/13/2024 from 11:02 AM - 12:54 PM to 12/18/2024 at 08:16AM - 03:29PM: 3 East findings room [ROOM NUMBER] - 2 tier bed side drawers scratched, missing keyhole, damaged and missing dry wall and hole in wall and missing dry wall. Water stain on ceiling tiles, bedside table missing paint on bottom base, holes at the baseboard for the B bed below the window. 3 East-318 dusty air conditioning/heater unit, cracked wall tile. room [ROOM NUMBER] Air conditioning/heater unit dusty, bedside tables missing paint on the bottom, cracked dry wall by door edge, scratched paint on air conditioning/heater. Bed A- 3 tier bedside table with missing top handle. Wall closet door missing right handle. Bed B - 2 tier dresser draw scratched veneer. room [ROOM NUMBER] - peeling paint on the wall opposite resident bed. room [ROOM NUMBER] Damaged dry wall and spoon in Air conditioner and heater unit. room [ROOM NUMBER] 2 tier dresser drawer with scratched brown colored veneer, missing keyhole, air conditioner/heater dusty wall edge, bedside table missing paint at bottom, missing tile on bottom edge of sink wall and 2 chipped tiles at sink edge, shower with rusty metal pipe, wall with missing paint above soap dish, bathroom tile in bathroom with brown colored edges. On 12/13/24 at 12:47 PM and 12/18/24 03:38 PM, room [ROOM NUMBER] - air conditioner/heater dusty and dresser drawers with scratched veneer. room [ROOM NUMBER] - dresser draw veneer scratched and missing paint on bedside table, fall matt with cracked edge. Exposed dry wall on sink edge and on bottom of wall. Missing key holes on 2 tier dressers with scratched veneer and air-conditioned dusty top and windowsill and grimy corners. room [ROOM NUMBER]- air conditioner/heater with paper and dried leaves in unit, missing key lock on the wall cabinet for A bed, sink drain left edge on wall brown in color pipe with brown grime on pipe, chipped dry wall on left side of wall edge below the sink and vital signs machine with dirty bottom foot pedals. room [ROOM NUMBER] the 2 tier dresser draw missing key lock, missing veneer on bottom edge scratched wood, 2 holes on wall where mount for electronics on floor. room [ROOM NUMBER] - 3 tier dresser right edge chipped, scratched veneer and mounted hand sanitizer dispenser not fully even with the wall. room [ROOM NUMBER] - bedside table missing paint, accordion bathroom door slat broken on lower edge, closet missing lock on left sided and tied closed with a broken metal hanger. Air conditioning unit dried leaves in unit and dusty grate. Wall with mismatched paint with dry wall patch by window under light by sink left and damaged dry wall on lower edged in room. room [ROOM NUMBER] hand sanitizer dispensed on wall not fully mounted to the wall screws visible on the right upper and lower side. room [ROOM NUMBER]- bedside table missing paint for A bed, footboard missing veneer and wood pulp exposed. There were 20 missing -1-inch tiles on handwashing sink edge. Air conditioned/heater unit dusty window, 2 tier dresser scratched veneer, damaged dry wall scratched on blue paint and right lower edge by sink. On 12/17/2024 at 03:07 PM, the 3 West bathroom was observed with multiple missing tiles on the floor of the bathroom and a 4 x 4 hole in wall. 3 West tub with clear plastic cup, cracker wrapper, vinyl glove, temperature probe machine and roach wing inside tub. Commode seat with dried brown stain on the right outer edge and left inner edge, rust on the legs, missing tile on the back wall of the commode and broken tile at hand washing sink. On 12/17/2024 at 03:29 PM, the 3 East pantry was observed and there were small black colored droppings under the microwave left draw, white colored water stain on the ice machine and there was a metal ladle spoon in the draw below the microwave. During an interview on 12/18/2024 at 03:00 PM, the Maintenance technician stated, when they do rounds three times during their shift to visually see any written or unwritten concerns. Observe walls that need to be painted if they are damaged and if the sheet rock needs to be put back in place. They paint as needed but can't say the last time painting was done on their unit, and they informed the Director of Maintenance that they need matching paint for units and replacement doors for resident bathrooms and some were ordered. Radiator cleaning is done quarterly, and it was done a month ago. When they encounter missing tile, they try to replace them and as soon as they identify a concern, and they prioritize their workload. They took two beside tables down last week to repair and if it can't be repaired, we get new bedside tables. We try to do all repairs in the shop downstairs. They have noticed the bedside tables are scratched up and we switch up the bedside table and want to renovate. Residents are here long term or short term, and we are providing comfort and care, visual stability in relation to the presentation of the room that creates environment for comfort and relaxation for resident. During an interview on 12/18/2024 at 03:47 PM, 3 West Licensed Practical Nurse # 1 stated, they have never seen tub cleaned and the tub is broken, and we do not use it. The tub contained a plastic cup cracker wrapping glove, roach wing and plastic temperature probe. Cleaned sometime this month and not sure when the tub was last cleaned. They do not clean the bottom of the medication cart. We don't use the commode. The medication carts are very old and if we try to clean them it is hard, and housekeeping used to wash. The last time they were washed was 2- 3 years ago. The unit needs to be homelike residents live here and this is the staff second home and what we like for us we like for them. f.) 4 West unit on 12/17/2024 from 12:26 PM - 4:13 PM - Nursing Station on 4 West peeling paint at nurses' station and opposite side of elevators. room [ROOM NUMBER]- mismatched paint, missing dry wall paint opposite nurse's station to right of unit door entrance from hallway. room [ROOM NUMBER]- 5 tier cart with cracked left edge, dusty edge on cart at bottom edge with oxygen tank. room [ROOM NUMBER]- bedside table missing paint. On 12/17/2024 at 12:52 PM -12:54 PM Room W403-bedside table missing pain on the bottom, Room W408- bedside table with chipped left edge. room [ROOM NUMBER]- bedside tale missing paint on bottom and room [ROOM NUMBER]- bedside table missing paint. 12/17/24 at 12:26 PM, room [ROOM NUMBER] wall outside room missing green paint has dry wall on wall area. On 12/17/2024 at 12:34 PM and 12/17/2024 04:09 PM, 12/18/2024 at 08:25 AM, the 4 West dining room - bedside table missing paint, all 4 - air conditioner and heater units are dusty and once opposite refrigerator contained a puzzle piece inside. Wheelchair with missing ??®?? of black right arm and left arm ripped with exposed fabric for resident sitting in the dining room. Rusty metal cart in day room/dining room. Wheelchair missing black veneer in some areas exposing white underneath approximately 2 inches for resident sitting in the dining room. On 12/18/2024 at 08:20 AM, room [ROOM NUMBER] and 409 bedside table missing paint, room [ROOM NUMBER]- brown crusty colored cream-colored stain on bottom of bedside table, room [ROOM NUMBER], room [ROOM NUMBER]- bedside table missing paint. room [ROOM NUMBER]- bedside table missing paint, dining room bedside table missing paint. On 12/19/24 at 10:56 AM, room [ROOM NUMBER] - sitting chair noted with tear in veneer in room. On On 12/18/24 at 3:57 PM, the 4 West unit tub noted with broken tile 4 total by the soiled storage area. During an interview on 12/17/2024 at 12:57 PM. Licensed Practical Nurse # 2 stated, each unit has a blood pressure cuff that is cleaned between every resident. They are not sure how often the bottom of the blood pressure cuff machine is cleaned, and they noticed it was dusty. The blood pressure machine is brought to resident's rooms, and you don't want to introduce dirty items into their environment, and it needs to be cleaned to keep functioning properly. For the rooms with dry wall that has not been painted the facility is in process of painting and replacing furniture piece by piece. During an interview on 12/17/2024 at 01:20 PM, Registered Nurse #5 stated, they look at resident's rooms while they observe the certified nursing assistants during care. The beside tables observed for excess items that may need to be thrown out. Certified nursing assistants wipe draws, remove items and throw items as needed out. The dresser drawers are cleaned for resident safety and hoarding will invite unwanted guests. This is the resident's home, we want it to be more homelike, make it look clean and have furniture to look like home. During an interview on 12/18/2024 at 02:51 PM, Maintenance Worker #2 stated, there are no concerns they are aware of for bedside tables on the 4th floor. They throw out bedside tables and there is renovation on the 4th floor and there are old tables on the 4th floor. We clean the radiators daily and we installed new covers on them this month. During an interview on 12/18/2024 at 03:14 PM, the Director of Maintenance stated, they do rounds daily, look at the maintenance book, make sure any environmental concerns are addressed by maintenance. The 2nd floor metal wall plate comes off due to wheelchairs hitting the wall. They are not sure when the refrigerator and wall unit was installed. 2 West room [ROOM NUMBER] stated they are reinstalling and working on the wall. Quarterly air conditioning/heater cleaning done, and it was last done in September. The damaged wall by the elevator damaged due to wheelchairs hitting it. The building is in the process of remodeling, and they have spare tables and they have placed an order for [REDACTED]. The room needs to be homelike for the residents to be comfortable, to be treated with respect, better environment for resident. Painting is done if needed. I do rounds to see what areas need to be painted and we do the painting. We look for safety issues, stained or missing tiles, environmental concerns and for resident safety. During an interview on 12/19/2024 at 01:18 PM, the Assistant Director of Nursing/Infection Preventionist stated, that the following units have had work done over the past 2 years- 2 East, 2 West and 4 East and work in in progress on 4 West unit. They do weekly rounds of the kitchen to look for cleanliness and they are not aware of any environmental concerns, and nothing reported to then for the kitchen in the year. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedMarch 23, 2023 1. The facility conducted a thorough investigation for the five identified residents with accident/incidents found to have been affected by the deficient practice. The thorough investigation included at a minimum: ??? Conducted observation of the identified residents. Including identification of any injuries as appropriate. The location where the identified incident occurred. Interactions and relationships between staff and the identified residents and or other residents. Interactions/relationships between residents to other residents as needed. ??? Conducted interviews with identified residents and representatives, witnesses, practitioners, hospital, or emergency room personnel if applicable. ??? Conducted record review of pertinent information related to the identified residents as appropriate, such as progress notes (nurse, social services, physician, therapist, as appropriate). Reports from hospital/emergency room records if applicable, lab or x ray reports, and medication administration reports. This was completed by 3/23/ 2023. 2. All other residents had the potential to be affected by this deficient practice. All accidents/ incidents from 2/21/2023 to 3/23/2023 were thoroughly reviewed and investigated to ensure thorough investigations completed and rule out any abuse, neglect, exploitation, or mistreatment. No other negative findings identified. This was completed 3/23/ 2023. The following thorough investigation included ??? Conducted observation of the identified residents. Including identification of any injuries as appropriate. The location where the identified incident occurred. Interactions and relationships between staff and the identified residents and or other residents. Interactions/relationships between residents to other residents as needed. ??? Conducted interviews with identified residents and representatives, witnesses, practitioners, hospital, or emergency room personnel if applicable. ??? Conducted record review of pertinent information related to the identified residents as appropriate, such as progress notes (nurse, social services, physician, therapist, as appropriate). Reports from hospital/emergency room records if applicable, lab or x ray reports, and medication administration reports. 3. The facility policy of Accidents/Incidents and Abuse Prohibition and Prevention was reviewed, and all staff members were re-educated on the facilities policy. This will be completed by 3/27/ 2023. All nursing staff educated on proper investigations and protocols including appropriate documentation. This will be completed by 3/27/ 2023. Which includes the following for each investigation ??? Conducted observation of the identified residents. Including identification of any injuries as appropriate. The location where the identified incident occurred. Interactions and relationships between staff and the identified residents and or other residents. Interactions/relationships between residents to other residents as needed. ??? Conducted interviews with identified residents and representatives, witnesses, practitioners, hospital, or emergency room personnel if applicable. ??? Conducted record review of pertinent information related to the identified residents as appropriate, such as progress notes (nurse, social services, physician, therapist, as appropriate). Reports from hospital/emergency room records if applicable, lab or x ray reports, and medication administration reports. 4. The Director of Nursing shall create an audit tool to monitor and review all Accidents and Incidents to ensure thorough investigations with all required documentation are gathered on the same shift that the incident occurs. The investigation and summary will then be completed within 5 days of the incident. This audit tool was created 3/23/2023 Audits shall be completed weekly x3 months and then monthly thereafter by the DON and/or designee. All audits will be brought to the QAPI committee and filed for reference. All Accidents/Incidents shall be reviewed at morning report with the IDT. 5. The responsible person will be the Director of Nursing. |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 8, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. Specifically multiple observations were made of resident rooms were observed with wood furniture scratched veneer, missing key holes, missing handles to dressers or wall cabinets, bedside tables were observed with missing paint on the lower leg areas. 2. ) resident rooms were observed with mismatched paint, holes in dry wall and duct tape on the floor, missing tile and/or grimy tile. 3. ) resident's wheelchair was observed with torn cushion and enteral feeding pumps and poles on 2 East and 2 West unit was observed with cream-colored stains on the pump and pole bottoms. 4). the whirlpool tub was noted to be dirty with discarded items inside and unit shared bathrooms were observed with discolored damaged or missing tiles. 4. ) the step leading to the trash dumpster was noted to be rusty with hole in metal stairs on the left side of the steps. 5). the wall behind in the 2nd floor dining room refrigerator and false pantry was observed with holes in back wall area. This was evident in 5 out of 6 units observed (2 East, 2 West, 3 East, 3 West and 4 West). The findings are: The facility's policy titled Cleaning and Disinfecting Resident Care Items and Equipment reviewed (MONTH) 2024 documented resident shared equipment including shared items and durable medical equipment shall be cleaned and disinfected according to the current Centers of Disease Control recommendations for disinfection and the Occupational Safety Health Administration Bloodborne Pathogens Standard. Durable medical equipment such as enteral feeding pumps, intravenous poles shall be cleaned after usage on the Environment Protection Agency registered antimicrobial list recommended by public health authorities. Medical storage equipment such as medication/treatment carts, cardiopulmonary resuscitation carts shall be cleaned when visibly soiled and on as needed basis. The facility policy titled 7 Step Cleaning Progress reviewed (MONTH) 2024 documented rooms the policy is to establish an efficient cleaning process and maintain a sanitary physical environment. Rooms will be cleaned thoroughly cleaned monthly or as needed. The following was observed during multiple observations conducted from 12/12/2024 to 12/19/ 2024. a.) Kitchen observations on 12/12/2024 from 09:21 AM - 10:58 AM, 12/16/2024 at 04:29 PM and 12/18/24 01:13 PM, include leaking kitchen kettle, cracked tile on the floor and missing tile. There is a gap in the wall edge by refrigerator #3 by wall mixer, cracked tile around the drain by the kettle and prep area, cracked tile by the stove partially replaced. The metal shelf of the kitchen holding washed dishes has grease residue on the metal shelves. Cracked corners on the resident fiberglass meal trays. Cracked floor and baseboard tiles in the dish room. Cracked floor tile under freezer # 2. Cracked tile by prep station thawing sink opposite refrigerator # 1. Visible hole under the sink pipe in the kitchen dish room. During an interview on 12/17/2024 at 11:28 AM, Dietary Aide # 7 stated, the kitchen tiles have been broken and maintenance comes to fix them when water comes up from floor drain areas. During an interview on 12/17/2024 at 10:32 AM, Dietary Aide # 4 stated, the leaking cooking kettle makes a puddle on the floor. There was a puddle in the kitchen at least 1-time last week after it rained heavy, and maintenance came to take care of it. b). On 12/17/24 at 10:29 AM, during kitchen trash disposal task with Dietary Aide # 4 the metal walking stairs leading to the bottom of the facility trash compactor were observed to be damaged. There was stored wheelchair parts visible under stairs area. On 12/19/2024 at 12:44 PM main floor staff dining lounge past the kitchen on lobby floor noted with black colored droppings under sink, food stain in freezer and bottom drawer noted with light brown colored food stain on the bottom of the lower drawers. c.)2nd Floor shared dining room by the elevator was observed from 12/12/2024 to 12/19/2024 with no radiator cover, metal exposed under mounted wall television area and the ice machine vent was dusty. There was a noticeable hole in the wall behind the refrigerator with a gap in between the refrigerator and the false pantry. 2nd Floor -2 East unit - on 12/12/2024 at 3:09PM and 12/17/2024 at 03:14PM, 12/17/2024 at 3:35PM - 3:37PM, the following was observed room [ROOM NUMBER]E-209 enteral feeding pump with dried cream-colored stains back of the pump. room [ROOM NUMBER]E - 206 has 6 strip of duct tape on floor holding tile down. The trash can by A bed is covered with a brown colored stain on the outside. 2 East- fan by room [ROOM NUMBER]E-222 noted to be dusty and has a white ribbon inside the fan and stamped with sticker inspected 8/20/ 2024. Metal fan by room [ROOM NUMBER]E-211 and 2E-215 dusty on outside with stamped inspected 7/16/ 2024. 2nd Floor on 12/12/2024 at 12/12/2024 at 04:46 PM, 12/17/2024 at 03:14 PM and 12/17/2024 at 03:40 PM, Elevator # 1- left and right lower edge damage to dry wall. Elevator # 2nd number elevator left lower edge and right side exposing dry wall covered with duct tape. Elevator # 3 has damage to dry wall on the 1/3 on left and ??®?? right side. 2 East -room [ROOM NUMBER] - 4 pieces of black duct tape holding floor tiles. 2 East shower room [ROOM NUMBER]/17/24 03:17 PM to 03:20PM, there was a gap in tile under sink in shower opposite nurses' station in 3 areas, shower drain with brown colored debris around hole in the drain cover. Large shower chair with rusty wheels. Large bathtub was dusty. The large bathtub contained the following a gray colored commode, pair of discarded vinyl gloves, empty bucket, brown colored debris on tub jets. Hoyer canvas blue wrap by the arms trap areas noted to be dusty on the fabric. d.) 2 West unit - room [ROOM NUMBER] P - on 12/12/2024 02:45 PM, 12/16/2024 at 10:38 AM and 12/17/2024 at 03:00 PM, the call light box on the wall was noted hanging from the wall over the resident's headboard on 12/12/ 2024. ) On 12/12/2024 at 02:49 PM, 12/16/2024 at 02:53 PM, 12/17/2024 02:57 PM and 12/18/2024 07:57 AM, room [ROOM NUMBER] P enteral feeding pump noted with cream-colored stains on the pump back area and pole noted with cream-colored stains on the bottom of the pole and the resident's floor. Air conditioning/heater unit damaged on left side by window bottom, unit is dusty with grey colored dust, dried leaves in adjustment knob. On 12/12/24 02:58 PM, 12/13/24 09:35 AM, the following was observed. room [ROOM NUMBER] wall divider by sink with chipped wood and air conditioning/heater unit dusty and unit crash cart with dusty bottom area. Medication Cart in the nurse's station observed with dust. room [ROOM NUMBER] enteral feeding pole with cream colored feeding on bottom dried and on enteral feeding pump front and back area. Air conditioning/heater unit dried leaves, gray colored dust in vent area. 2 West bathroom- tub with stains in tub, plastic cup on right side of seat, white towel, belt with white colored dust, shower chair for larger residents with brown colored stain on bottom area, cracked tile under sink on left edge approximately 1 ??®??Ñ x ??®??ó inch. Bottom wheels for larger shower chair with rust on all 6 wheels. Wound Care treatment cart for 2 West on - 12/18/24 09:41 AM empty sharps container noted with cream colored tape affixed to the right side of the sharps container holder horizontally to keep it closed. Environment 2 West- 12/12/24 11:46 AM 2 West Hoyer lift dusty plastic foot pad and missing paint on both Hoyer leg area. 2 West Medication room on 12/16/2024 at 10:05 AM veneer on cabinet door labeled pill crusher and thermometer had ripped veneer on upper cabinet middle left door. During an interview on 12/18/2024 at 08:29 AM, the Housekeeper #1 stated, when they clean the bedside table, they scrape down the table and mop it to get the floor clean. They are not sure who they report to if the table bottom is crusty or missing paint. This is where the residents eat, and residents put their feet on, and you want it to be comfortable. e.) 3rd East and 3 West units were observed from 12/13/2024 from 11:02 AM - 12:54 PM to 12/18/2024 at 08:16AM - 03:29PM: 3 East findings room [ROOM NUMBER] - 2 tier bed side drawers scratched, missing keyhole, damaged and missing dry wall and hole in wall and missing dry wall. Water stain on ceiling tiles, bedside table missing paint on bottom base, holes at the baseboard for the B bed below the window. 3 East-318 dusty air conditioning/heater unit, cracked wall tile. room [ROOM NUMBER] Air conditioning/heater unit dusty, bedside tables missing paint on the bottom, cracked dry wall by door edge, scratched paint on air conditioning/heater. Bed A- 3 tier bedside table with missing top handle. Wall closet door missing right handle. Bed B - 2 tier dresser draw scratched veneer. room [ROOM NUMBER] - peeling paint on the wall opposite resident bed. room [ROOM NUMBER] Damaged dry wall and spoon in Air conditioner and heater unit. room [ROOM NUMBER] 2 tier dresser drawer with scratched brown colored veneer, missing keyhole, air conditioner/heater dusty wall edge, bedside table missing paint at bottom, missing tile on bottom edge of sink wall and 2 chipped tiles at sink edge, shower with rusty metal pipe, wall with missing paint above soap dish, bathroom tile in bathroom with brown colored edges. On 12/13/24 at 12:47 PM and 12/18/24 03:38 PM, room [ROOM NUMBER] - air conditioner/heater dusty and dresser drawers with scratched veneer. room [ROOM NUMBER] - dresser draw veneer scratched and missing paint on bedside table, fall matt with cracked edge. Exposed dry wall on sink edge and on bottom of wall. Missing key holes on 2 tier dressers with scratched veneer and air-conditioned dusty top and windowsill and grimy corners. room [ROOM NUMBER]- air conditioner/heater with paper and dried leaves in unit, missing key lock on the wall cabinet for A bed, sink drain left edge on wall brown in color pipe with brown grime on pipe, chipped dry wall on left side of wall edge below the sink and vital signs machine with dirty bottom foot pedals. room [ROOM NUMBER] the 2 tier dresser draw missing key lock, missing veneer on bottom edge scratched wood, 2 holes on wall where mount for electronics on floor. room [ROOM NUMBER] - 3 tier dresser right edge chipped, scratched veneer and mounted hand sanitizer dispenser not fully even with the wall. room [ROOM NUMBER] - bedside table missing paint, accordion bathroom door slat broken on lower edge, closet missing lock on left sided and tied closed with a broken metal hanger. Air conditioning unit dried leaves in unit and dusty grate. Wall with mismatched paint with dry wall patch by window under light by sink left and damaged dry wall on lower edged in room. room [ROOM NUMBER] hand sanitizer dispensed on wall not fully mounted to the wall screws visible on the right upper and lower side. room [ROOM NUMBER]- bedside table missing paint for A bed, footboard missing veneer and wood pulp exposed. There were 20 missing -1-inch tiles on handwashing sink edge. Air conditioned/heater unit dusty window, 2 tier dresser scratched veneer, damaged dry wall scratched on blue paint and right lower edge by sink. On 12/17/2024 at 03:07 PM, the 3 West bathroom was observed with multiple missing tiles on the floor of the bathroom and a 4 x 4 hole in wall. 3 West tub with clear plastic cup, cracker wrapper, vinyl glove, temperature probe machine and roach wing inside tub. Commode seat with dried brown stain on the right outer edge and left inner edge, rust on the legs, missing tile on the back wall of the commode and broken tile at hand washing sink. On 12/17/2024 at 03:29 PM, the 3 East pantry was observed and there were small black colored droppings under the microwave left draw, white colored water stain on the ice machine and there was a metal ladle spoon in the draw below the microwave. During an interview on 12/18/2024 at 03:00 PM, the Maintenance technician stated, when they do rounds three times during their shift to visually see any written or unwritten concerns. Observe walls that need to be painted if they are damaged and if the sheet rock needs to be put back in place. They paint as needed but can't say the last time painting was done on their unit, and they informed the Director of Maintenance that they need matching paint for units and replacement doors for resident bathrooms and some were ordered. Radiator cleaning is done quarterly, and it was done a month ago. When they encounter missing tile, they try to replace them and as soon as they identify a concern, and they prioritize their workload. They took two beside tables down last week to repair and if it can't be repaired, we get new bedside tables. We try to do all repairs in the shop downstairs. They have noticed the bedside tables are scratched up and we switch up the bedside table and want to renovate. Residents are here long term or short term, and we are providing comfort and care, visual stability in relation to the presentation of the room that creates environment for comfort and relaxation for resident. During an interview on 12/18/2024 at 03:47 PM, 3 West Licensed Practical Nurse # 1 stated, they have never seen tub cleaned and the tub is broken, and we do not use it. The tub contained a plastic cup cracker wrapping glove, roach wing and plastic temperature probe. Cleaned sometime this month and not sure when the tub was last cleaned. They do not clean the bottom of the medication cart. We don't use the commode. The medication carts are very old and if we try to clean them it is hard, and housekeeping used to wash. The last time they were washed was 2- 3 years ago. The unit needs to be homelike residents live here and this is the staff second home and what we like for us we like for them. f.) 4 West unit on 12/17/2024 from 12:26 PM - 4:13 PM - Nursing Station on 4 West peeling paint at nurses' station and opposite side of elevators. room [ROOM NUMBER]- mismatched paint, missing dry wall paint opposite nurse's station to right of unit door entrance from hallway. room [ROOM NUMBER]- 5 tier cart with cracked left edge, dusty edge on cart at bottom edge with oxygen tank. room [ROOM NUMBER]- bedside table missing paint. On 12/17/2024 at 12:52 PM -12:54 PM Room W403-bedside table missing pain on the bottom, Room W408- bedside table with chipped left edge. room [ROOM NUMBER]- bedside tale missing paint on bottom and room [ROOM NUMBER]- bedside table missing paint. 12/17/24 at 12:26 PM, room [ROOM NUMBER] wall outside room missing green paint has dry wall on wall area. On 12/17/2024 at 12:34 PM and 12/17/2024 04:09 PM, 12/18/2024 at 08:25 AM, the 4 West dining room - bedside table missing paint, all 4 - air conditioner and heater units are dusty and once opposite refrigerator contained a puzzle piece inside. Wheelchair with missing ??®?? of black right arm and left arm ripped with exposed fabric for resident sitting in the dining room. Rusty metal cart in day room/dining room. Wheelchair missing black veneer in some areas exposing white underneath approximately 2 inches for resident sitting in the dining room. On 12/18/2024 at 08:20 AM, room [ROOM NUMBER] and 409 bedside table missing paint, room [ROOM NUMBER]- brown crusty colored cream-colored stain on bottom of bedside table, room [ROOM NUMBER], room [ROOM NUMBER]- bedside table missing paint. room [ROOM NUMBER]- bedside table missing paint, dining room bedside table missing paint. On 12/19/24 at 10:56 AM, room [ROOM NUMBER] - sitting chair noted with tear in veneer in room. On On 12/18/24 at 3:57 PM, the 4 West unit tub noted with broken tile 4 total by the soiled storage area. During an interview on 12/17/2024 at 12:57 PM. Licensed Practical Nurse # 2 stated, each unit has a blood pressure cuff that is cleaned between every resident. They are not sure how often the bottom of the blood pressure cuff machine is cleaned, and they noticed it was dusty. The blood pressure machine is brought to resident's rooms, and you don't want to introduce dirty items into their environment, and it needs to be cleaned to keep functioning properly. For the rooms with dry wall that has not been painted the facility is in process of painting and replacing furniture piece by piece. During an interview on 12/17/2024 at 01:20 PM, Registered Nurse #5 stated, they look at resident's rooms while they observe the certified nursing assistants during care. The beside tables observed for excess items that may need to be thrown out. Certified nursing assistants wipe draws, remove items and throw items as needed out. The dresser drawers are cleaned for resident safety and hoarding will invite unwanted guests. This is the resident's home, we want it to be more homelike, make it look clean and have furniture to look like home. During an interview on 12/18/2024 at 02:51 PM, Maintenance Worker #2 stated, there are no concerns they are aware of for bedside tables on the 4th floor. They throw out bedside tables and there is renovation on the 4th floor and there are old tables on the 4th floor. We clean the radiators daily and we installed new covers on them this month. During an interview on 12/18/2024 at 03:14 PM, the Director of Maintenance stated, they do rounds daily, look at the maintenance book, make sure any environmental concerns are addressed by maintenance. The 2nd floor metal wall plate comes off due to wheelchairs hitting the wall. They are not sure when the refrigerator and wall unit was installed. 2 West room [ROOM NUMBER] stated they are reinstalling and working on the wall. Quarterly air conditioning/heater cleaning done, and it was last done in September. The damaged wall by the elevator damaged due to wheelchairs hitting it. The building is in the process of remodeling, and they have spare tables and they have placed an order for [REDACTED]. The room needs to be homelike for the residents to be comfortable, to be treated with respect, better environment for resident. Painting is done if needed. I do rounds to see what areas need to be painted and we do the painting. We look for safety issues, stained or missing tiles, environmental concerns and for resident safety. During an interview on 12/19/2024 at 01:18 PM, the Assistant Director of Nursing/Infection Preventionist stated, that the following units have had work done over the past 2 years- 2 East, 2 West and 4 East and work in in progress on 4 West unit. They do weekly rounds of the kitchen to look for cleanliness and they are not aware of any environmental concerns, and nothing reported to then for the kitchen in the year. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedMarch 23, 2023 1. The facility conducted a thorough investigation for the five identified residents with accident/incidents found to have been affected by the deficient practice. The thorough investigation included at a minimum: ??? Conducted observation of the identified residents. Including identification of any injuries as appropriate. The location where the identified incident occurred. Interactions and relationships between staff and the identified residents and or other residents. Interactions/relationships between residents to other residents as needed. ??? Conducted interviews with identified residents and representatives, witnesses, practitioners, hospital, or emergency room personnel if applicable. ??? Conducted record review of pertinent information related to the identified residents as appropriate, such as progress notes (nurse, social services, physician, therapist, as appropriate). Reports from hospital/emergency room records if applicable, lab or x ray reports, and medication administration reports. This was completed by 3/23/ 2023. 2. All other residents had the potential to be affected by this deficient practice. All accidents/ incidents from 2/21/2023 to 3/23/2023 were thoroughly reviewed and investigated to ensure thorough investigations completed and rule out any abuse, neglect, exploitation, or mistreatment. No other negative findings identified. This was completed 3/23/ 2023. The following thorough investigation included ??? Conducted observation of the identified residents. Including identification of any injuries as appropriate. The location where the identified incident occurred. Interactions and relationships between staff and the identified residents and or other residents. Interactions/relationships between residents to other residents as needed. ??? Conducted interviews with identified residents and representatives, witnesses, practitioners, hospital, or emergency room personnel if applicable. ??? Conducted record review of pertinent information related to the identified residents as appropriate, such as progress notes (nurse, social services, physician, therapist, as appropriate). Reports from hospital/emergency room records if applicable, lab or x ray reports, and medication administration reports. 3. The facility policy of Accidents/Incidents and Abuse Prohibition and Prevention was reviewed, and all staff members were re-educated on the facilities policy. This will be completed by 3/27/ 2023. All nursing staff educated on proper investigations and protocols including appropriate documentation. This will be completed by 3/27/ 2023. Which includes the following for each investigation ??? Conducted observation of the identified residents. Including identification of any injuries as appropriate. The location where the identified incident occurred. Interactions and relationships between staff and the identified residents and or other residents. Interactions/relationships between residents to other residents as needed. ??? Conducted interviews with identified residents and representatives, witnesses, practitioners, hospital, or emergency room personnel if applicable. ??? Conducted record review of pertinent information related to the identified residents as appropriate, such as progress notes (nurse, social services, physician, therapist, as appropriate). Reports from hospital/emergency room records if applicable, lab or x ray reports, and medication administration reports. 4. The Director of Nursing shall create an audit tool to monitor and review all Accidents and Incidents to ensure thorough investigations with all required documentation are gathered on the same shift that the incident occurs. The investigation and summary will then be completed within 5 days of the incident. This audit tool was created 3/23/2023 Audits shall be completed weekly x3 months and then monthly thereafter by the DON and/or designee. All audits will be brought to the QAPI committee and filed for reference. All Accidents/Incidents shall be reviewed at morning report with the IDT. 5. The responsible person will be the Director of Nursing. |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 8, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during post survey revisit for complaint number NY 797 completed on 3/8/2023 the facility did not ensure that fall occurrences were thoroughly investigated to rule out abuse, neglect, or mistreatment for [REDACTED]. Specifically, the facility concluded the six A/I report ruled out abuse, neglect or mistreatment without obtaining statements or interviews from the relevant staff and witnesses to the incident. The finding is: The facility's policy titled Accident/Incident (A/I) revised 10/13/22 defined accident as an unexpected event that can cause a resident bodily injury which included lacerations requiring suturing, fractures, second- or third-degree burns, concussion, or head injury with neurological changes. Incident is defined as unexpected, unintended event that can cause a resident superficial injury which included scratches, abrasions, blisters, ecchymosis areas, bruises, first degree burns, lacerations, superficial skin tears, hematoma and head injury without neurological changes. Occurrence is defined as any event or circumstance that is not consistent with the routine operation of the nursing facility or routine care of the resident. An occurrence is without any resulting injury, examples included falls without injury and reddened areas. An accident/incident/occurrence report must be prepared for all occurrences. The report must be initiated before the end of the shift on which it occurred. The nursing supervisor or charge nurse must be notified, must immediately investigate the accident/incident, and complete the A/I report form. The Charge nurse or RNS will obtain statement from the resident as applicable and from all relevant staff on duty utilizing the appropriate investigative reports. The Director of Nursing (DON) and the Administrator will review all accident/incident and occurrence reports for completeness, appropriateness and corrective measures. The facility's policy titled Abuse Prohibition and Prevention revised 1/26/23 documented the facility is responsible for prompt and thorough investigation of all alleged violations and occurrences. Upon completion of the investigatory process by authorized personnel, all facts and information shall be reviewed with the Administrator or designee. It is the policy of the facility that reports of abuse (mistreatment, neglect, abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Investigation will begin upon learning of a potential incident of abuse and the investigation will be completed within five business days. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary if any for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include conducting observation, record review and interviews as appropriate with the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies such as other investigatory agencies, and hospital or emergency room personnel. Clinical staff shall utilize the occurrence/incident report and immediately notifies the Director of Nursing and/or Administrator for any alleged violations. 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data set (MDS - an assessment tool) dated 12/7/22 documented the resident with Brief Interview for Mental status (BIMS) score of 10 indicating moderately impaired in cognition. The resident required extensive assistance of one person for bed mobility, transfer, and locomotion. Resident #2's Occurrence report dated 2/26/23 at 10:40 PM documented that Resident#2 was sitting in a wheelchair at the nursing station, stood up and put themself on the floor, on their knees. The resident was unable to give account of the incident because of confusion. The occurrence report did not have statements from Licensed Practical Nurse (LPN) and the assigned Certified Nurse's Aide (CNA) only documented they did not know what happened. The facility's investigative summary documented the resident has behavior of placing themself on the floor and will get up unassisted. The investigation documented abuse, neglect or mistreatment has been ruled out and signed by the DON and Administrator on 3/1/ 23. 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with BIMS of 10 indicating moderately impaired in cognition. The resident required total dependence of 2 persons for bed mobility, transfers, and toilet use and could not walk. Resident #3's Occurrence report dated 2/24/23 at 3:25 PM documented that the resident stated they were getting up to go to the bathroom and they slid out of the bed. LPN #1 was called by LPN #2 who observed the resident sitting on their buttocks on the bedside mat next to their bed. The report did not have a statement from LPN #2 who observed the resident on the floor. The Nurse's Progress Notes (NPN) documented that Resident#3 was found sitting on the side of the bed full of feces, resident unable to give account of incident. The facility's investigative summary completed on 2/28/23 documented the call bell was functioning but did not activate and Resident #3 was unable to give an account of the fall. The occurrence report documented different information that the resident stated they were trying to get up to go to the bathroom and slid out of bed. The NPN documented that the resident was found full of feces and the investigation documented that abuse, neglect or mistreatment was ruled out and was signed by DON and Administrator on 2/28/ 23. Resident#3's Occurrence Report dated 3/3/23 at 9:30 PM documented that the resident was observed on the floor next to their bed by their roommate. The occurrence report lacked documented evidence that statements were obtained from LPN #2, CNA #1 and Resident#3's roommate who had observed the resident on the floor. The facility's investigative summary completed on 3/7/23 documented Resident#3 was unable to give account due to cognitive impairment. There was no documentation of a statement from the resident's roommate or a root cause as to how the resident was found on the floor. The investigation ruled out abuse, neglect or mistreatment and was signed by DON and Administrator on 3/7/ 23. 3) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with 0 BIMS and staff assessment indicated resident with moderately impaired cognition. The resident required total assist with bed mobility and transfers with 2 persons assistance. The Resident Occurrence Report dated 3/3/23 documented the Resident #4 was found on a floormat next to an ultra-low bed. The report lacked documented statements from the LPN and CNA. The facility's investigative summary documented the resident had behavior of rolling off the bed on to the floormat. The investigative summary documented that abuse, neglect or mistreatment was ruled out and was signed by DON and Administrator on 3/7/ 23. The Resident Occurrence Report dated 3/5/23 documented Resident #4 had a low bed and was observed sliding themself out of bed onto the floor. The resident was assisted back to bed. Mattress placed on window side of the bed. The occurrence report lacked documented evidence that statements were obtained from LPN, CNA and the person who witnessed the resident sliding off the bed. The facility's investigative summary completed on 3/7/23 documented the resident has behavior of rolling off the bed into the floormat and ruled out abuse, neglect and mistreatment and was signed by DON and Administrator on 3/7/ 23. 4) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with BIMS of 10 indicating moderately impaired cognition. The resident required total assistance of two persons with bed mobility, transfer and toilet use. The Resident occurrence report dated 3/5/23 at 6:50 PM documented resident was found on bedside mat and resident stated they rolled out of bed. Resident denies pain, no injury noted. Resident with behavior of crawling off the bed onto floormat. The report did not have statements from the LPN and CNA. The facility's investigative report completed on 3/7/23 documented Resident has a behavior of rolling off the bed onto the floormat. The resident is extensive assistance of 2 persons for all care and Hoyer lift with transfers. The investigation ruled out abuse, neglect or mistreatment occurred and was signed by DON and Administrator on 3/7/ 23. The facility submitted an audit of A/Is that were conducted between 1/13/23 to 3/6/ 23. The audit documented there were 7 A/Is for 1/2023, 27 A/I for 2/2023 and 7 A/I for 3/ 2023. The DON audited all A/Is and the audit did not document any issues or concerns. Resident #2 was observed on 3/8/23 at 2:26 PM sleeping in bed. The bed is low position. Resident #3 was observed at 2:30 PM being provided care by the staff. Resident #4 was observed at 2:40 PM sleeping in bed with bed in low position, has mattress on the right side of the bed and floormat on left side of bed. Resident #5 was observed at 2:35 PM lying in low bed and floormats on the right side of bed. During an interview with the DON on 3/7/2023 at 3:45 PM stated that they started as DON on 2/20/ 2023. DON stated that the previous Assistant Director of Nursing (ADON) left A/I(s) that were not completed on 3/6/ 23. The DON stated they reviewed the A/I(s) for completion which included statements from the nurse and CNA assigned to the resident, printing of progress notes and update the care plan and they conclude the investigation. DON reviewed Resident #2's 2/26/23 occurrence and acknowledged that there was no statement from the nurse and CNA did not sign their statement. ADON concluded the investigation on 3/1/23 and DON signed off based on previous statements from the staff stating Resident #1 throws self on the floor. Resident #3's occurrence dated 2/24/23 the DON acknowledged that there was no statement from LPN # 2. The occurrence dated 3/3/23, the DON acknowledged it lacked statements from LPN, CNA and the roommate who witnessed the incident. DON stated they signed off that the investigation and ruled out abuse because of Resident #3's behavior of putting self on the floormat. DON acknowledged that Resident #4's occurrence dated 3/3/23 and 3/5/23 have no statements from nurse and the CNA but concluded the incident based on resident's behavior of throwing self on the floor as stated by staff. Resident #5 occurrence dated 3/5/23 have no statements from the LPN and CNA. The DON stated they concluded and ruled out abuse and neglect on 3/7/23 because Resident #5 also has a behavior of putting self on floormats. DON stated when an incident happens the RNS is responsible for collecting statements from the staff. The facility investigation should be completed within 5 days. DON stated they were instructed by their corporate to write up the report, so they wrote and concluded some of the investigation on 3/7/ 23. DON also stated that they have to educate the staff on how to complete A/I report including obtaining statements from staff/residents who witnessed the incident or was present when incident occurred. During an interview with the Administrator on 3/7/2023 at 4:32 PM stated that the A/I audit was done by the DON and A/I reports were discussed during morning meeting and there were no issues identified. Administrator reviewed the six occurrence reports. The Administrator stated Resident #2's occurrence report dated 2/26/23, need more statements from staff but was concluded and abuse ruled out based on care plan and documented behaviors. Administrator stated Resident #3's occurrence dated 2/24/23 and 3/3/23 needs more statements from the LPN and CNA. The investigation is complete but could be more thorough to have the statements from the staff. Resident #4's occurrence report dated 3/3/23 and 3/5/23 needs to be completed. Administrator stated the facility have not finished the investigation but also acknowledged that the investigation was concluded and signed. Resident #5 occurrence dated 3/5/23, the Administrator stated they signed that the investigation is concluded. Administrator stated they have 5 days to complete the investigation. Administrator also stated it is hard to pick up the pieces because there is a change in management. During a reinterview with the DON on 3/8/23 at 4:24 PM they stated that a fall with major injury, unwitnessed fall, bruising, misappropriation of funds, sexual assault, neglect, sexual allegation requires a thorough investigation because it could be a potential abuse or neglect. The DON Stated they have to investigate right away because they have to report within 2 hours. The DON stated that the 6 A/I(s) that were reviewed had behaviors and does not need a thorough investigation because they did not feel there was Abuse. The DON further stated that it is not a complete investigation because not everybody signed the investigation and need statements from the staff. The DON stated the staff statements should be written within the shift the incident occurred. DON was able to conclude the investigations based on record review and notes and ruled out abuse without the staff statements. The resident has the right to fall and being that it is a behavior of the resident, DON did not think they have to run over and get statements. DON stated they audited the A/I(s) on a daily basis and A/I(s) were also reviewed in the morning meeting to determine if incident is a potential abuse that requires reporting within 2 hours. DON stated a QAPI meeting conducted on 3/8/23 discussed abuse, potential abuse and A/Is there were no issues identified. 10 NYCRR 415. 4 b (3) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 8, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during post survey revisit for complaint number NY 797 completed on 3/8/2023 the facility did not ensure that fall occurrences were thoroughly investigated to rule out abuse, neglect, or mistreatment for [REDACTED]. Specifically, the facility concluded the six A/I report ruled out abuse, neglect or mistreatment without obtaining statements or interviews from the relevant staff and witnesses to the incident. The finding is: The facility's policy titled Accident/Incident (A/I) revised 10/13/22 defined accident as an unexpected event that can cause a resident bodily injury which included lacerations requiring suturing, fractures, second- or third-degree burns, concussion, or head injury with neurological changes. Incident is defined as unexpected, unintended event that can cause a resident superficial injury which included scratches, abrasions, blisters, ecchymosis areas, bruises, first degree burns, lacerations, superficial skin tears, hematoma and head injury without neurological changes. Occurrence is defined as any event or circumstance that is not consistent with the routine operation of the nursing facility or routine care of the resident. An occurrence is without any resulting injury, examples included falls without injury and reddened areas. An accident/incident/occurrence report must be prepared for all occurrences. The report must be initiated before the end of the shift on which it occurred. The nursing supervisor or charge nurse must be notified, must immediately investigate the accident/incident, and complete the A/I report form. The Charge nurse or RNS will obtain statement from the resident as applicable and from all relevant staff on duty utilizing the appropriate investigative reports. The Director of Nursing (DON) and the Administrator will review all accident/incident and occurrence reports for completeness, appropriateness and corrective measures. The facility's policy titled Abuse Prohibition and Prevention revised 1/26/23 documented the facility is responsible for prompt and thorough investigation of all alleged violations and occurrences. Upon completion of the investigatory process by authorized personnel, all facts and information shall be reviewed with the Administrator or designee. It is the policy of the facility that reports of abuse (mistreatment, neglect, abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. Investigation will begin upon learning of a potential incident of abuse and the investigation will be completed within five business days. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary if any for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include conducting observation, record review and interviews as appropriate with the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies such as other investigatory agencies, and hospital or emergency room personnel. Clinical staff shall utilize the occurrence/incident report and immediately notifies the Director of Nursing and/or Administrator for any alleged violations. 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data set (MDS - an assessment tool) dated 12/7/22 documented the resident with Brief Interview for Mental status (BIMS) score of 10 indicating moderately impaired in cognition. The resident required extensive assistance of one person for bed mobility, transfer, and locomotion. Resident #2's Occurrence report dated 2/26/23 at 10:40 PM documented that Resident#2 was sitting in a wheelchair at the nursing station, stood up and put themself on the floor, on their knees. The resident was unable to give account of the incident because of confusion. The occurrence report did not have statements from Licensed Practical Nurse (LPN) and the assigned Certified Nurse's Aide (CNA) only documented they did not know what happened. The facility's investigative summary documented the resident has behavior of placing themself on the floor and will get up unassisted. The investigation documented abuse, neglect or mistreatment has been ruled out and signed by the DON and Administrator on 3/1/ 23. 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with BIMS of 10 indicating moderately impaired in cognition. The resident required total dependence of 2 persons for bed mobility, transfers, and toilet use and could not walk. Resident #3's Occurrence report dated 2/24/23 at 3:25 PM documented that the resident stated they were getting up to go to the bathroom and they slid out of the bed. LPN #1 was called by LPN #2 who observed the resident sitting on their buttocks on the bedside mat next to their bed. The report did not have a statement from LPN #2 who observed the resident on the floor. The Nurse's Progress Notes (NPN) documented that Resident#3 was found sitting on the side of the bed full of feces, resident unable to give account of incident. The facility's investigative summary completed on 2/28/23 documented the call bell was functioning but did not activate and Resident #3 was unable to give an account of the fall. The occurrence report documented different information that the resident stated they were trying to get up to go to the bathroom and slid out of bed. The NPN documented that the resident was found full of feces and the investigation documented that abuse, neglect or mistreatment was ruled out and was signed by DON and Administrator on 2/28/ 23. Resident#3's Occurrence Report dated 3/3/23 at 9:30 PM documented that the resident was observed on the floor next to their bed by their roommate. The occurrence report lacked documented evidence that statements were obtained from LPN #2, CNA #1 and Resident#3's roommate who had observed the resident on the floor. The facility's investigative summary completed on 3/7/23 documented Resident#3 was unable to give account due to cognitive impairment. There was no documentation of a statement from the resident's roommate or a root cause as to how the resident was found on the floor. The investigation ruled out abuse, neglect or mistreatment and was signed by DON and Administrator on 3/7/ 23. 3) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with 0 BIMS and staff assessment indicated resident with moderately impaired cognition. The resident required total assist with bed mobility and transfers with 2 persons assistance. The Resident Occurrence Report dated 3/3/23 documented the Resident #4 was found on a floormat next to an ultra-low bed. The report lacked documented statements from the LPN and CNA. The facility's investigative summary documented the resident had behavior of rolling off the bed on to the floormat. The investigative summary documented that abuse, neglect or mistreatment was ruled out and was signed by DON and Administrator on 3/7/ 23. The Resident Occurrence Report dated 3/5/23 documented Resident #4 had a low bed and was observed sliding themself out of bed onto the floor. The resident was assisted back to bed. Mattress placed on window side of the bed. The occurrence report lacked documented evidence that statements were obtained from LPN, CNA and the person who witnessed the resident sliding off the bed. The facility's investigative summary completed on 3/7/23 documented the resident has behavior of rolling off the bed into the floormat and ruled out abuse, neglect and mistreatment and was signed by DON and Administrator on 3/7/ 23. 4) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident with BIMS of 10 indicating moderately impaired cognition. The resident required total assistance of two persons with bed mobility, transfer and toilet use. The Resident occurrence report dated 3/5/23 at 6:50 PM documented resident was found on bedside mat and resident stated they rolled out of bed. Resident denies pain, no injury noted. Resident with behavior of crawling off the bed onto floormat. The report did not have statements from the LPN and CNA. The facility's investigative report completed on 3/7/23 documented Resident has a behavior of rolling off the bed onto the floormat. The resident is extensive assistance of 2 persons for all care and Hoyer lift with transfers. The investigation ruled out abuse, neglect or mistreatment occurred and was signed by DON and Administrator on 3/7/ 23. The facility submitted an audit of A/Is that were conducted between 1/13/23 to 3/6/ 23. The audit documented there were 7 A/Is for 1/2023, 27 A/I for 2/2023 and 7 A/I for 3/ 2023. The DON audited all A/Is and the audit did not document any issues or concerns. Resident #2 was observed on 3/8/23 at 2:26 PM sleeping in bed. The bed is low position. Resident #3 was observed at 2:30 PM being provided care by the staff. Resident #4 was observed at 2:40 PM sleeping in bed with bed in low position, has mattress on the right side of the bed and floormat on left side of bed. Resident #5 was observed at 2:35 PM lying in low bed and floormats on the right side of bed. During an interview with the DON on 3/7/2023 at 3:45 PM stated that they started as DON on 2/20/ 2023. DON stated that the previous Assistant Director of Nursing (ADON) left A/I(s) that were not completed on 3/6/ 23. The DON stated they reviewed the A/I(s) for completion which included statements from the nurse and CNA assigned to the resident, printing of progress notes and update the care plan and they conclude the investigation. DON reviewed Resident #2's 2/26/23 occurrence and acknowledged that there was no statement from the nurse and CNA did not sign their statement. ADON concluded the investigation on 3/1/23 and DON signed off based on previous statements from the staff stating Resident #1 throws self on the floor. Resident #3's occurrence dated 2/24/23 the DON acknowledged that there was no statement from LPN # 2. The occurrence dated 3/3/23, the DON acknowledged it lacked statements from LPN, CNA and the roommate who witnessed the incident. DON stated they signed off that the investigation and ruled out abuse because of Resident #3's behavior of putting self on the floormat. DON acknowledged that Resident #4's occurrence dated 3/3/23 and 3/5/23 have no statements from nurse and the CNA but concluded the incident based on resident's behavior of throwing self on the floor as stated by staff. Resident #5 occurrence dated 3/5/23 have no statements from the LPN and CNA. The DON stated they concluded and ruled out abuse and neglect on 3/7/23 because Resident #5 also has a behavior of putting self on floormats. DON stated when an incident happens the RNS is responsible for collecting statements from the staff. The facility investigation should be completed within 5 days. DON stated they were instructed by their corporate to write up the report, so they wrote and concluded some of the investigation on 3/7/ 23. DON also stated that they have to educate the staff on how to complete A/I report including obtaining statements from staff/residents who witnessed the incident or was present when incident occurred. During an interview with the Administrator on 3/7/2023 at 4:32 PM stated that the A/I audit was done by the DON and A/I reports were discussed during morning meeting and there were no issues identified. Administrator reviewed the six occurrence reports. The Administrator stated Resident #2's occurrence report dated 2/26/23, need more statements from staff but was concluded and abuse ruled out based on care plan and documented behaviors. Administrator stated Resident #3's occurrence dated 2/24/23 and 3/3/23 needs more statements from the LPN and CNA. The investigation is complete but could be more thorough to have the statements from the staff. Resident #4's occurrence report dated 3/3/23 and 3/5/23 needs to be completed. Administrator stated the facility have not finished the investigation but also acknowledged that the investigation was concluded and signed. Resident #5 occurrence dated 3/5/23, the Administrator stated they signed that the investigation is concluded. Administrator stated they have 5 days to complete the investigation. Administrator also stated it is hard to pick up the pieces because there is a change in management. During a reinterview with the DON on 3/8/23 at 4:24 PM they stated that a fall with major injury, unwitnessed fall, bruising, misappropriation of funds, sexual assault, neglect, sexual allegation requires a thorough investigation because it could be a potential abuse or neglect. The DON Stated they have to investigate right away because they have to report within 2 hours. The DON stated that the 6 A/I(s) that were reviewed had behaviors and does not need a thorough investigation because they did not feel there was Abuse. The DON further stated that it is not a complete investigation because not everybody signed the investigation and need statements from the staff. The DON stated the staff statements should be written within the shift the incident occurred. DON was able to conclude the investigations based on record review and notes and ruled out abuse without the staff statements. The resident has the right to fall and being that it is a behavior of the resident, DON did not think they have to run over and get statements. DON stated they audited the A/I(s) on a daily basis and A/I(s) were also reviewed in the morning meeting to determine if incident is a potential abuse that requires reporting within 2 hours. DON stated a QAPI meeting conducted on 3/8/23 discussed abuse, potential abuse and A/Is there were no issues identified. 10 NYCRR 415. 4 b (3) | Plan of Correction: N/A Plan of correction not approved or not required |