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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 16, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY 641), the facility did not ensure the residents' right to be free from physical abuse by nursing home staff. This was evidence for 1 out of 10 residents reviewed (Resident #1). Specifically, on 10/25/2024 at 2:52 PM, in the nursing station as Resident #1 approached Admission Clerk #1 with the arms raised to Admission Clerk #1's neck area. Admission Clerk #1 pushed Resident #1 with both hands and Resident #1 fell backward on the floor and hit their head on the desk behind them. Resident #1 was transferred to the hospital for evaluation and returned to the facility with no new orders. The findings are: The facility's Policy and Procedure Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/ Exploitation and Mistreatment, effective date 10/2022, documented the purpose of the policy to ensure that every resident have the right to be free from abuse, neglect, mistreatment, misappropriation of resident property and exploitation. To provide a safe environment and protect residents from abuse. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 08/23/2024, documented Resident #1 had severe cognitive impairment. A Facility's Incident Investigation Report dated 10/25/2024, documented that at approximately 3:00 PM, code Doctor Strong was called, and Resident #1 was observed on the floor behind the nursing station. The video surveillance was reviewed, and it was observed that prior to the incident, Resident #1 was sitting in the front of the nursing station. When Admission Clerk #1 entered the nursing station, Resident #1 followed Admission Clerk # 1. Admission Clerk #1 turned around as Resident #1 walked toward Admission Clerk # 1. Resident #1 raised their arms as they walked toward Admission Clerk #1, and Admission Clerk #1 pushed Resident #1 away. As a result, Resident #1 fell backward onto their bottom and hit the cabinet behind them. The New York City Police was called, but no arrest was made. The facility determined that the occurrence was unsubstantiated for physical abuse. Admission Clerk #1 acted out of fright and reacted to Resident #1's behavior. A Care Plan for Resident at risk for being a victim of abuse, neglect, and/or mistreatment due to congregate living initiated on 11/17/2020, target date 02/25/2025, documented interventions to advise resident to seek out staff assistance if having difficulty with others. A Care Plan Note dated 10/25/2024 at 5:57 PM, written by the former Director of Nursing documented they arrived at the Doctor Strong code (Doctor Strong code means the resident is agitated). Resident #1 fell and hit their head. Resident #1 alleged that a staff member hit them. Resident #1 noted with redness to the back of their head and ice was applied. Resident #1 denied pain. A full body assessment was done, and no other new bumps, bruising, redness, irritation, or swelling were noted. Resident #1's range of motion was intact. The primary medical doctor was made aware, and Resident #1 was transferred to the Hospital emergency department. A physician progress notes [REDACTED].#1 noted to have violent behavior towards staff. During their behavior, Resident #1 fell and hit their head. No Loss of Conscious and was sent to Emergency Department. A Physician order [REDACTED].#1 to the hospital for evaluation. A Hospital After Visit Summary dated 10/25/2024, documented Resident #1 was evaluated for hitting their head; computerized Tomography was done and there were no injuries. A video surveillance record dated 10/25/2024 at 2:52 PM, showed Admission Clerk #1 was standing by the desk in the nursing station. Certified Nurse Assistant #1 was sitting at the desk with their back turned to Admission Clerk # 1. Licensed Practical Nurse #1 was standing at the medication cart. Resident #1 walked into the nursing station, passed Licensed Practical Nurse #1, approached the Admission Clerk #1 with raised their hand, and attempted to reach the Admission Clerk's neck area. The Admission Clerk #1 pushed Resident #1 with both hands, and they fell backward on the floor. During an interview on 12/05/2024 at 11:20 AM, Admission Clerk #1 stated they do not want to answer any questions. During an interview on 12/05/2024 at 12:48 PM, Certified Nursing Assistant #1 stated Resident #1 was known for aggressive behavior in the past. Certified Nursing Assistant #1 stated around 3:00 PM while sitting in the nursing station at the computer saw Resident #1 walk into the nursing station and walk toward the Admission Clerk # 1. Resident #1 raise their hands toward the Admission Clerk # 1. Certified Nursing Assistant #1 further stated they saw Resident #1 fall backward but did not see what caused them to fall. Certified Nursing Assistant #1 stated there was no time to intervene because it happened very fast. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 called Doctor Strong, (when the resident agitated), and the Nursing Supervisor came and took over. During an interview on 12/6/2024 at 2:03 PM, Certified Nursing Assistant #2 stated on 10/25/2024, after 2:00 PM, they were sitting in the nursing station. Certified Nursing Assistant #2 stated they observed Resident #1 enter the nursing station, pass them, and was talking. Certified Nursing Assistant #2 stated they thought Resident #1 was talking to the nurse who was behind them. Certified Nursing Assistant #2 stated that they were sitting with their back to Resident #1 and heard Resident #1 say, You called me N but they did not know who Resident #1 was referring to. Certified Nursing Assistant #2 stated they turned around because they heard a noise like a wrestle and dump. Certified Nursing Assistant #2 stated they observed Resident #1 was on the floor and holding the back of their head. Certified Nursing Assistant #2 stated Resident #1 had a lump on the back of their head but did not complain of pain. Certified Nursing Assistant #2 stated Resident #1 said the Admission Clerk #1 hit them. Certified Nursing Assistant #2 stated they asked the Admission Clerk #1 what happened, and they said that Resident #1 tried to attack them, and they defended themselves. Certified Nursing Assistant #2 stated they were showed the video, and saw Admission Clerk #1 hit or push Resident #1, causing Resident #1 to fall on the floor. Certified Nursing Assistant #2 stated they are not supposed to touch the resident. Certified Nursing Assistant #2 stated in a situation when residents become aggressive, staff should back away or remove themselves from the situation and call for help. Certified Nursing Assistant #2 stated if there is no way to escape, the staff is supposed to raise their hands to block the hit, but they cannot push or hit the resident. During a telephone interview on 12/05/2024 at 1:20 PM, Licensed Practical Nurse #1 stated Resident #1 came to the nursing station on 10/25/24 after lunch (could remember the exact time) and was approaching Admission Clerk #1 aggressively. Licensed Practical Nurse #1 stated Resident #1 passed them, and they did not feel they could have the opportunity to intervene and stop Resident # 1. Licensed Practical Nurse #1 stated they saw Resident #1 raise their arms toward the Admission Clerk #1 but did not see if the Admission Clerk #1 pushed Resident # 1. Licensed Practical Nurse #1 stated they turned to the left to grab the walkie-talkie that was on the desk and called the Doctor Strong code. Licensed Practical Nurse #1 stated at the time they turned around; Resident #1 was already on the floor. Licensed Practical Nurse #1 stated that the Registered Nurse Supervisor assessed Resident # 1. Licensed Practical Nurse #1 stated Resident #1 had a bump on the back of the head and did not complain of pain. Licensed Practical Nurse #1 stated the Medical Doctor was called and ordered to send Resident #1 | Plan of Correction: ApprovedJanuary 3, 2025 I. Immediate Corrections Resident #1 was thoroughly assessed following the incident and promptly transferred to the hospital emergency room . After a complete evaluation, the resident returned to the facility with no injuries. Admission Clerk #1 was immediately suspended pending a comprehensive investigation. Upon the conclusion of the investigation, the staff member was terminated in accordance with facility policy and standards. The incident was reported to NYSDOH on 10/25/2024 at 15:00, complaint number NY 641. All facility staff were educated on abuse prevention. II. Identification of Other Residents No other residents were identified to have complaints regarding staff treatment. Social worker followed up with the residents of the unit to provide emotional and psychosocial support. The residents stated that they were not fearful of any additional incident. The comprehensive care plans of all residents were checked to ensure there was a plan in place to prevent abuse, and specific interventions that were resident centered. All care plans were found in compliance with the protection of our residents. A copy of resident care plan is available in the EMR. III. Systemic Changes The facilitys policy and procedure titled Abuse Prevention was reviewed and found appropriate. All clinical and non-clinical staff (All RNs, LPNs, C.N.A.s, Admissions Staff, Recreation Staff, Housekeeping Staff, Engineering Staff, Administrative Staff, Social Service Staff, Rehabilitation Staff, and Dietary Staff) were re-educated by the Nurse Educator/Designee on the policy/procedure. These sessions reinforced the processes and responsibilities outlined in the Abuse Prevention policy to ensure consistent implementation across all departments. The attendance sheet will be kept on file for validation. The facility will continue to provide education upon hire, annually and as needed on the Policy and Procedure on abuse, neglect, and mistreatment. Staff hourly observational rounds of all residents will continue. IV. QA Monitoring An audit tool was developed to ensure that no abuse, neglect, or mistreatment occurred. The Audit tool will concentrate on resident complaints about staff treatment. Audits of 5 residents will be performed by Social Services weekly x 4 weeks, then monthly for 2 months. Any negative findings have immediate corrective action taken and reported immediately to the Administrator. Results of the audits will be reported monthly and reviewed by the QAPI committee. Continuation, modification, or discontinuation of audits will be based on QAPI committees recommendations. Person Responsible: Director of Social Services |