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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 5, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an abbreviated survey (NY 381), the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This was evident for one (1) out of three (3) residents sampled (Resident #1) Specifically, on 10/03/2023 during the 11:00 PM-7:00 AM shift, Certified Nursing Assistant #3 stated they did not provide personal care to Resident #1 because they forgot and falsely documented care was provided. The surveillance video was reviewed and confirmed that Certified Nursing Assistant #3 did not provide any activity of daily living care to Resident # 1. On 10/04/2023 at 8:30 AM, Resident #1 was observed saturated with urine. Certified Nursing Assistant #3 was terminated. The findings are: The facility's Policy and Procedure titled Resident Abuse, Neglect and Exploitation revised 04/2023, documented the facility ensures all residents are free from abuse, neglect, misappropriation of resident property and exploitation. The facility's Policy and Procedure titled Activities of Daily Living Protocol revised 01/2023, documented the facility will implement measures to assess the resident's ability to perform activity of daily living and based on the assessment, implement treatment and services for resident's needs to maintain, improve and prevent decline. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool), dated 09/13/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. The Comprehensive Care Plan titled: Activity of Daily Living Tasks dated 08/07/2023, documented interventions to provide incontinent care. Resident Nursing Instructions dated 07/19/2022, documented Resident #1 was incontinent of bowel and bladder, and they required dependent assistance by staff for incontinent care every shift. The facility's investigation dated 10/16/2023, documented at approximately 8:15 AM on 10/04/2023, Certified Nursing Assistant #1 observed Resident #1 saturated with urine when they went to provide personal care. Initially, Certified Nursing Assistant #3 provided the facility with a statement documenting that they did resident monitoring and Resident #1 did not require changing. The Director of Nursing interviewed Certified Nursing Assistant #3 who was assigned to Resident #1 during the 11:00 PM-7:00 AM shift, and they stated they did not render care to Resident #1 because they forgot. The surveillance video was reviewed and confirmed that Certified Nursing Assistant #3 did not provide any activity of daily living care to Resident # 1. Certified Nursing Assistant #3 was terminated on 10/04/2023, for confirmed patient neglect and mistreatment as well as falsification of documentation. Employee Statement of Occurrence (no date specified) by Certified Nursing Assistant #3, documented Certified Nursing Assistant #3 did resident monitoring at 11:00 PM (no date provided) and checked on Resident # 1. Resident #1 stated they were okay. Certified Nursing Assistant #3 did not notice anything unusual. Resident #1 appeared to be clean and dry, and they did not need to be changed. Employee Statement of Occurrence dated 10/12/2023 by Certified Nursing Assistant #1 documented on 10/04/2023 at 8:30 am, Certified Nursing Assistant #1 observed Resident #1 soaked with urine. During an interview on 12/31/2024 at 11:17 am, Resident #1 stated the staff does not disrespect them. Several attempts made to interview Certified Nursing Assistant #1 but was unsuccessful, letter was sent on 01/13/ 2025. Several attempts made to interview Certified Nursing Assistant #3 but was unsuccessful, letter was sent on 01/13/ 2025. During a telephone interview on 01/28/2025 at 11:36 AM, Social Worker stated Resident #1 reported to them that they weren't changed all night. During a telephone interview on 01/28/2025 at 11:50 AM, Director of Nursing stated Certified Nursing Assistant #3 was assigned to Resident #1 on the 11:00 PM-7:00 AM shift and admitted to not providing care to Resident # 1. During a telephone interview on 01/28/2025 at 2:44 PM, the Administrator stated they were away and received a call from the facility informing them of the incident in (MONTH) 2023 (can't recall date or time). 10 NYCRR 415. 12(a)(3). | Plan of Correction: ApprovedFebruary 28, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #1 On 10/4/23, the resident was immediately provided with ADL care by the assigned CNA for the day shift after it was determined that the resident had not received ADL care on the 11-7 shift. On 02/25/2025 the residents ADL self-care deficit care plan and CNA nursing care instructions were reviewed by the Interdisciplinary Team (IDT) to ensure that necessary services to maintain good nutrition, grooming, and personal and oral hygiene were properly addressed. No revisions were needed to the plan of care. The Nurse Manager reviewed the plan of care with the unit staff and the staffs responsibility to provide ADL care for this resident who requires total assistance with ADL care. CNA #3 was terminated on 10/4/ 23. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. Between 02/25/2025 and 03/25/2025 a full facility audit will be conducted by the IDT members to identify and assess all residents who require assistance with ADLs. This assessment will involve reviewing care plans to ensure that the necessary ADL assistance is clearly identified and outlined for each resident. Any immediate needs will be addressed promptly with staff providing the required care and support. Any revisions to a residents ADL plan of care will be reviewed with the responsible unit staff. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, DNS, and RN/MDS Coordinator will review and revise, as needed, the policy and procedure for Activities of Daily Living (ADL) including staff responsibility to provide ADL care as outlined in the individual plan of care for dependent residents. The DNS/designee will provide additional education to all CNAs regarding their responsibilities in providing ADL care for dependent residents. The education will focus on the importance of providing timely and appropriate assistance with ADLs, understanding and adhering to individual care plans and CNA nursing instructions, and recognizing signs of unmet ADL needs. This training will be incorporated into the orientation of new Nursing staff members and will be reviewed annually and as needed. RN Supervisors will monitor compliance through routine observational rounds to ensure that ADL care is provided consistently and in accordance with each residents care plan. Immediate corrective actions, including staff re-education and, if necessary, disciplinary action, will be implemented for any deviations or failure to provide required ADL care. The IDT will be responsible for reviewing and updating each residents care plan to ensure it accurately reflects their ADL needs and preferences. Care plans will include specific details regarding the frequency and type of assistance required, as well as any special considerations (e.g., preferred timing or specific requests for assistance). IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with the provision of ADL care per the plan of care. The RN/designee will audit 20% of residents requiring different levels of ADL assistance monthly for the next three months, then quarterly for the following three quarters. Each audit sample will include ADL dependent residents. All audit findings will be reported to the Administrator and DNS monthly. Corrective actions, such as staff reeducation or revision to the plan of care, will be implemented as needed. The DNS/designee will report ADL audit findings to the QA Committee on a quarterly basis for evaluation, discussion, and follow-up corrective action. At the end of the fourth quarter, the QAPI Committee will assess the need for ongoing monitoring and determine the appropriate frequency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 5, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an abbreviated survey, (NY 381), the facility did not ensure the resident's right to be treated with respect and dignity including the right to be free from physical or chemical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 10/04/2023, Registered Nurse Supervisor #1 documented received a call from License Practical Nurse #1 at approximately 8:20 AM. License Practical Nurse #1 and Certified Nursing Assistant #1 stated Resident #1's left arm was tied to the siderail of the bed with a sock. Registered Nurse Supervisor #1 interviewed Resident #1 and Resident #1 stated they were tied up all night and was experiencing pain. There were no signs of bruised or injuries and an x-ray was ordered. The findings are: The facility's Policy and Procedure titled Resident Abuse, Neglect and Exploitation revised 04/2023, documented the facility ensures all residents are free from abuse, neglect, misappropriation of resident property and exploitation. This also includes the right to be free from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility's Policy and Procedure titled, Physical Restraints revised 10/2024, documented the facility recognizes and respects the right of their residents to be free from physical and chemical restraints unless its use is medically indicated and permitted under applicable laws, guidelines, and standards. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool), dated 09/13/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. The facility's investigation dated 10/16/2023, documented on 10/04/2023 at approximately 8:15 AM, Certified Nursing Assistant #1 observed Resident #1's left arm tied with a sock to the siderail of the bed. They removed the sock immediately and reported it to License Practical Nurse # 1. Resident #1 was interviewed by the Social Worker #1, and they reported their arm was tied with a sock to the side rail all night. The facility's investigation revealed Certified Nursing Assistant #3 was assigned to Resident #1 on the 11:00 PM -7:00 AM shift, and the surveillance video showed they did not provide any activity of daily living care to Resident # 1. On 10/04/2023 at approximately 12:00 PM, Certified Nursing Assistant #4 reported to the Director of Nursing that Certified Nursing Assistant #2 called the facility at approximately 9:00 AM requesting that Certified Nursing Assistant #4 untie Resident #1's hand from the siderail. The Facility's investigation concluded restraints were used. The x-ray results dated 10/04/2023 documented no obvious fracture or dislocation. Employee Statement of Occurrence (no date specified) by Certified Nursing Assistant #3 documented at 11:00 PM, when monitoring residents, (no date was provided) Resident # 1. Was okay. Certified Nursing Assistant #3 did not notice anything unusual. Resident #1 appeared to be clean and dry and did not need to be changed. Employee Statement of Occurrence dated 10/04/2023, by Registered Nurse Supervisor #1 documented they received a call from License Practical Nurse #1 at approximately 8:20 AM, License Practical Nurse #1 and Certified Nursing Assistant #1 stated that they observed Resident #1's left arm tied to the bed rail with a sock. Registered Nurse Supervisor #1 interviewed Resident #1 and Resident #1 stated they were tied up all night and was experiencing pain. Physical assessment done and no bruises were noted, and an x-ray was ordered. Untitled statement dated 10/04/2023 by Certified Nursing Assistant #2 documented they did not restrain Resident #1 on 10/03/ 2023. Untiled statement dated 10/05/2023, by Receptionist documented on 10/04/2023 at approximately 8:45 AM, Certified Nursing Assistant #2 called the facility asking to speak to Certified Nursing Assistant # 4. Statement further documented Certified Nursing Assistant #2's tone sound urgent. Employee Statement of Occurrence dated 10/12/2023, by Certified Nursing Assistant #1 documented on 10/04/2023 at 8:30 AM, Certified Nursing Assistant #1 observed Resident #1 soaked with urine and their left hand was tied to the siderail of the bed. During an interview on 12/31/2024 at 11:17 am, Resident #1 stated the staff does not disrespect them and that they have never tied their wrist. Several attempts made to interview Certified Nursing Assistant #1 but was unsuccessful, letter sent on 01/13/ 25. Several attempts made to interview Certified Nursing Assistant #3 but was unsuccessful, letter sent on 01/13/ 25. During a telephone interview on 01/13/2025 at 1:31 PM, License Practical Nurse #1 stated Certified Nursing Assistant #1 reported to them on 10/04/2023 (can't recall the time) that Resident #1's left arm was observed tied to the bedrail with a sock. Certified Nursing Assistant #1 had removed the sock, and they did not observe any bruises to Resident #1's skin. License Practical Nurse #1 stated they reported it to their supervisor immediately. During a telephone interview on 01/13/2025 at 1:50 PM, Certified Nursing Assistant #4 stated they were sitting at the nurse's station when they answered a call on the facility's phone. Certified Nursing Assistant #4 stated it was approximately 9:00 AM and Certified Nursing Assistant #2 asked them if they can check on Resident # 1. Certified Nursing Assistant #4 stated Certified Nursing Assistant #2 stated they tied Resident #1's hand. Certified Nursing Assistant #4 stated they did not witness Resident #1's hand tied, and they reported to their supervisor what Certified Nursing Assistant #2 told them. During a telephone interview on 01/21/2025 at 10:45 AM, Certified Nursing Assistant #2 stated they were assigned to Resident #1 on the 3:00 PM-11:00 PM shift 10/03/ 2023. They denied restraining Resident # 1. Certified Nursing Assistant #2 stated they went back to Resident #1's room at 10:00 PM to check to see if Resident #1's incontinent brief was dry. They stated they pulled the sheet and Resident #1's incontinent brief was dry, and they did not observe anything on Resident # 1. They stated they did not call or speak to anyone at the facility on 10/04/ 2023. During a telephone interview on 01/28/2025 at 11:36 AM, Social Worker stated Registered Nurse Supervisor #1 informed them on 10/04/2023 (can't recall the time) that Resident #1's wrist was tied with a sock to the bedrail. Social Worker stated they met with Resident #1 (on the same day, can't recall the time) and Resident #1 stated their hand was tied to the siderail with a sock all night and they were experiencing pain. Social Worker also stated Resident #1 stated they weren't changed all night. During a telephone interview on 01/28/2025 at 11:50 AM, Director of Nursing stated they concluded Certified Nursing Assistant #2 restrained Resident #1 because Certified Nursing Assistant #2 was the last known staff that cared for Resident # 1. Certified Nursing Assistant #3 was assigned to Resident #1 on the 11:00 PM-7:00 AM shift and admitted to not providing care to Resident # 1. Director of Nursing stated Certified Nursing Assistant #2 called the facility on 10/04/2023 and spoke to Certified Nursing Assistant # 4. They reviewed the surveillance video and observed Certified Nursing Assistant #4 rushing to Resident #1's room after speaking on the phone. During a telephone interview on 01/28/2025 at 2:44 PM, the Administrator stated they were away and received a call from the facility informing them of the incident in (MONTH) 2023 (can't recall date or tim | Plan of Correction: ApprovedFebruary 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #1 On 10/4/23, the resident was seen and examined by the Assistant Director of Nursing Services (ADNS), with no visible signs of injury. The attending physician was notified, and an order for [REDACTED]. The resident does not exhibit any medical symptoms that would necessitate the use of a restraining device. On 10/4/23, the Social Work (SW) Director contacted the local police department to report the incident for further investigation. The case was subsequently referred to the district attorney's office for review. The resident was re-examined by the attending physician on 10/6/23, who reviewed the left-hand x-ray results. CNA #2 was terminated on 10/4/ 23. The Potential for Abuse Care Plan was reviewed on 12/16/24 and again on 2/25/25, the interdisciplinary team (IDT) determined that there was no need to revise the plan of care. The IDT continues to monitor for any signs or symptoms of abuse or unnecessary use of physical restraint devices. There have been no restraint concerns since this event in 2023. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents in the facility have been identified as potentially affected by the same practice. A comprehensive audit was conducted by the Nurse Supervisors and the Interdisciplinary Care Plan Team (IDCPT) on 02/25/2025 for all residents to identify any use of physical restraint devices. No residents were found to be using any physical restraint devices. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, Director of Nursing (DNS), and Medical Director will review and revise, as necessary, the facilitys policies and procedures related to physical restraints. This review will include protocols for assessing the use of restraints, obtaining physician orders, securing resident representative consent, and ensuring proper care planning for restraints. The DNS/designee will continue to provide additional education to all staff regarding their responsibilities related to the policies and procedures for physical restraint. This education will be included in the orientation for new clinical team members and reviewed annually or as needed. RN Supervisors will monitor compliance through routine observational rounds and review physician orders [REDACTED]. Immediate corrective actions, including staff re-education and reassessment of restraints will be taken as needed. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with protocols related to the use of restraints. The DNS/designee will audit all residents identified with restraint devices monthly for the next 3 months, and then quarterly for the following 3 quarters. The DNS will report all restraint audit findings to the Administrator monthly for the first 3 months, and then at the end of each subsequent quarter for the next 3 quarters. Corrective actions, including education and obtaining physician orders [REDACTED]. The DNS will report all physical restraint audit findings to the QA Committee monthly for the first 3 months, and then at the end of each subsequent quarter for the next 3 quarters. At the end of this period, the Committee will evaluate the need for continued monitoring, determine the appropriate frequency, and decide on any additional corrective actions to implement. |