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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, 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 th | 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 th | 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 Details not available | 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 Details not available | Plan of Correction: N/A Plan of correction not approved or not required |