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Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey completed on 2/28/2022 the facility did not ensure that services provided met professional standards. This was identified for one (Resident #17) of 5 residents reviewed for medication administration. Specifically, Licensed Practical Nurse (LPN) #1 administered a crushed Potassium Chloride (supplement) Extended-Release tablet to Resident # 17. The Manufacturer's specifications for the Potassium supplement specified that the medication should not be crushed. The finding is: The undated facility policy and procedure for Crushing of Medications documented the Physician should order the crushing of medications. The physician must document the rationale why a medication must be crushed. The Medication Administration Record [REDACTED]. Resident #17 was admitted with [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. During a medication pass observation with LPN #1 on 2/16/2022 at 10 AM LPN #1 crushed the Potassium Chloride 20 meq tablet, mixed the crushed medication with yogurt and administered the Potassium Chloride Extended-Release tablet to Resident # 17. LPN #1 was interviewed on 2/16/2022 at 10 AM and stated they did not know they could not crush the Potassium Chloride medication and that a physician's orders [REDACTED]. LPN #1 stated that the tablet was too big for the resident to swallow and that is why they (LPN #1) were crushing the Potassium Chloride tablets. The Pharmacist was interviewed on 2/18/2022 at 12:00 PM and stated that nurses should not crush an Extended-Release Potassium Chloride tablet. When an Extended-Release tablet is crushed, the absorption of the medication is affected thereby affecting the efficacy of the medication. The Director of Nursing Services (DNS) was interviewed on 2/18/2022 at 5:00 PM and stated LPN #1 should not have crushed the Potassium Chloride medication without a physician's orders [REDACTED]. The nurse should have called the Physician and the Physician would have evaluated the medication use. 415. 11(c)(3)(i) | Plan of Correction: ApprovedMarch 24, 2022 Part I. Immediate Corrective Action for Residents affected: i. Resident #1 MDS was completed and submitted 2/25/ 2022. ii. RN #15 was educated and counseled by the Administrator on timely encoding and transmittal of the MDS assessment. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Administrator or designee will perform an audit of all residents who was discharged from the facility in the past 90 days to ensure that all Minimum Data Set assessment was encoded and transmitted timely. All negative findings will be corrected immediately. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy Titled MDS was reviewed by DON. No changes required. ii. MDS staff will be in-serviced by the Director of Nursing Services on timely encoding and transmittal the of Minimum Data Set assessment. iii. In-service lesson plan and attendance records will be kept on file for validation Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Administrator or Designee will do a weekly audit x 4 weeks and monthly x 3 to ensure that submissions are completed in a timely manner. All negative findings will be corrected immediately. ii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Administrator or designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey completed on [DATE], the facility did not ensure that Minimum Data Set (MDS) assessment was encoded and transmitted timely for each resident including a subset of items upon a residents' transfer, reentry, discharge and or death. This was identified for one (Resident #1) of one resident reviewed for the Resident Assessment Task. Specifically, after Resident #1 expired on [DATE] there was no documented evidence that the MDS was encoded and transmitted to the Centers for Medicare & Medicaid Services (CMS) System. The finding is: Resident #1 was admitted with [DIAGNOSES REDACTED]. The Entry MDS assessment dated [DATE] was in place and documented accepted in the CMS System. The Admission MDS assessment dated [DATE] was in place and documented accepted in the CMS System. The MDS with an assessment reference date of [DATE] documented the Tracking/Discharge MDS assessment for Death was 115 days overdue for completion and submission to the CMS System. A Nursing Progress note dated [DATE] at 8:22 AM documented the resident was found unresponsive in bed at 7:56 AM, not breathing, no pulse, no heart or breath sounds auscultated. There was no code called because the resident had orders for Do Not Intubate and Do Not Resuscitate in the chart. The Registered Nurse (RN#15), Minimum Data Set Coordinator, was interviewed on [DATE] at 10:12 AM and stated they were responsible for completing the discharge MDS assessment. RN #15 stated that they were working from home and had a lot going on during that time. RN #15 stated that they should have completed a death in facility MDS assessment for Resident #1 and that was an oversite. The Director of Nursing Services was interviewed on [DATE] at 4:13 PM and stated the MDS assessment should have been completed the day after the resident expired. The Director of Nursing Services stated that the MDS assessment coordinator was responsible for completing the assessment. The Director of Nursing Services stated that if the MDS coordinator was not available to complete the assessment, they should have designated the MDS assessor to complete the assessment. 415. 11 | Plan of Correction: ApprovedMarch 28, 2022 Part I. Immediate Corrective Action for Residents affected: i. The clinical chart was reviewed for Resident #303 no longer resides in the facility. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Director of Nursing Services or designee will perform an audit of the 24 Hour Reports in the past 3 months to ensure that the occurrence report investigations are accessible and complete in order to make a determination if abuse, neglect, or mistreatment has occurred. Part III. Systemic Changes made so the deficiency will not reoccur: i. DON and Administrator reviewed and revised policy titled Accident/Incident/Occurrence Reports (Patients/Residents) in order to reflect occurrence reports being documented on the facility's Electronic Health Record (EHR) platform, Point Click Care (PCC). ii. All staff will be in serviced on the policy and procedure Accident/Incident/Occurrence Reports (Patients/Residents). iii. In-service lesson plan and attendance records will be kept on file for validation. iv. All accidents/incidents will be reviewed during morning meeting to ensure an occurrence report was initiated. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing Services/Designee will monitor and review the electronic log and compare with the 24 hour report and morning meeting for documentation and completion. ii. The DNS or designee will conduct an audit weekly x 4 then monthly X 3 months. The Director of Nursing Services or designee will address and correct any negative findings immediately. iii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing Services/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 230) completed on 2/28/2022, the facility did not ensure that a thorough investigation was completed to rule out neglect following a report of an incident. This was identified for one (Resident #303) of two residents reviewed for Accidents. Specifically, Resident #303 was found on the floor of their room on 6/20/2021, however, there was no documentation that an Occurrence Report investigation was completed. The finding is: The facility's policy titled Accident/Incident/Occurrence Reports (Patients/Residents) dated 9/2016 documented that all falls and/or lowered to the floor are to have an Occurrence Report completed for investigation and Quality Assurance (QA) review. Resident #303 was admitted with [DIAGNOSES REDACTED]. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The resident needed extensive physical assistance of one person for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and bathing. The Nursing Progress Note dated 6/20/2021 documented that at 5:15 AM the resident had an unwitnessed fall. A Certified Nursing Assistant (CNA) reported to a noise in the resident's room. The resident was observed sitting on the floor in front of their unlocked wheelchair with their right lower extremity flexed under and their left leg extended. The facility did not have an Occurrence Report related to the fall on 6/20/ 2021. The Director of Nursing Services (DNS) was interviewed on 2/23/2022 at 3:20 PM and stated that the facility was unable to find the Occurrence Report that was completed for the resident's fall on 6/20/ 2021. The DNS stated that an Occurrence Report should be completed after a resident's fall to rule out abuse, mistreatment, and or neglect. The Registered Nurse (RN) Risk Manager/Assistant Director of Nursing Services (ADNS) was interviewed on 2/23/2022 at 4:25 PM and stated that an Occurrence Report should be completed to make sure that there was no abuse, mistreatment, or neglect. The Risk Manager stated that the Occurrence Report documents information such as the date and time, room number, whether it happened on the 1st, 2nd, or 3rd shift, where the resident was when they fell . The Occurrence Report also documents if the resident fell from their bed or wheelchair and if there was any injury to make sure there was no abuse, mistreatment, or neglect. The Risk Manager stated that an Occurrence Report for Resident #303's fall on 6/20/2021 could not be found. 415. 4(b)(1)(ii) | Plan of Correction: ApprovedMarch 24, 2022 Part I. Immediate Corrective Action for Residents affected: i. Resident #307's clinical chart was reviewed and no longer resides in the facility. ii. LPN #8 was educated by the DON to notify residents' representative of the residents' change in condition and their transfer to the hospital. Nursing Supervisor no longer works at the facility. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The clinical charts of all residents that were transferred to the hospital in the past 30 days were audited to ensure resident's representatives were notified of their transfer to the hospital. No negative findings were identified. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy titled Change in Condition was reviewed by DON and no revisions were required. All RNs and LPNs will be educated on the Change in Condition policy. ii. Unit Managers will be responsible to review all change in conditions/hospital transfers to ensure residents' representative will be notified of the residents' change in condition and their transfer to the hospital. iii. Any change in condition/transfer to hospital will be discussed in daily morning report to ensure family/designated representative notifications are done. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing or Designee will audit all change in conditions and transfers to the hospital weekly X 4 then monthly X 3 to ensure all resident representative notifications pertaining to a resident change of condition and transfer to the hospital. The Director of Nursing Services will address and correct any negative findings immediately. ii. The result of all audits will be reported to QAPI committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details 2012 NFPA 101: 19. 1. 6 Minimum Construction Requirements. 19. 1. 6. 1 Health care occupancies shall be limited to the building construction types specified in Table 19. 1. 6. 1, unless otherwise permitted by 19. 1. 6. 2 through 19. 1. 6. 7. (See 8. 2. 1. ) Life Safety Code Section 19. 1. 6 and Table 19. 1. 6. 1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. This requirement is not met as evidenced by: Based on observation, staff interview and documentation review, the facility did not ensure that the nursing home building that is built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000)) was not more than two stories in height. The facility did not provide an approved time limited waiver from CMS and they did not provide evidence that mitigating factors were implemented while the deficiency exists. The findings are: During the Life Safety Code survey on 02/16/22 between 10:00am and 2:45pm, multiple observations made during the survey of the building revealed that the steel structural members (joists, beams) above the suspended ceiling assembly throughout the building were not provided with fire proofing. Examples include but are not limited to bare steel beams above the ceiling in the corridors on the 1st, 2nd, and Ground floors. Due to the lack of fire proofing on steel structural members and the lack of a fire resistance rated ceiling assembly (inlay drop ceiling), this building is considered to be a Type II (000) Unprotected, Non-combustible structure. The Life Safety Code prohibits Type II (000) buildings from being more than two stories in height. In an interview on 02/16/2021 at 10:30am, the Assistant Administrator/Director of Maintenance stated that the facility is in the process of doing an FSES and would be filing for a time limited waiver or recurring waiver based on the outcome of the FSES report. During the offsite life safety code offsite post survey revisit on 5/11/2022, no approved time limited waiver from CMS was provided. Additionally, no evidence was provided that mitigating factors such as fire watchs and additional fire drills beyond the required level had been implemented as stated in the plan of correction. 2012 NFPA 101: 19. 1. 6. 1. 8. 2. 1, 8. 2. 1. 2 2012 NFPA 220: 4. 1 10 NYCRR 415. 29 10 NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 24, 2022 Part I. Immediate Corrective Action for Residents affected: i. One resident was affected by the deficient practice. ii. Resident #66 physician was educated by the Medical Director regarding the resident care and no documented evidence that the resident's change in skin condition was evaluated or addressed in timely manner. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Director of Nursing or Designee will audit all residents with pressure injuries for primary physician documentation. All negative findings will be corrected immediately. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy titled Physician Services was reviewed by DON, Administrator and Medical Director and no revisions were necessary ii. All Primary physicians will be in-serviced on timely documentations of new pressure injuries by the Medical Director/designee. iii. In-service lesson plan and attendance records will be kept on file for validation Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Medical Director or designee will do a weekly audit x 4 then monthly X3 to ensure timely physician documentation of new pressure injuries. All negative findings will be addressed and corrected immediately. ii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Medical Director/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey completed on 2/28/2022 the facility failed to ensure that each resident received care, consistent with professional standard of practice to prevent Pressure Ulcer (PU) development and to promote healing. This was identified for one (Resident #66) of three residents reviewed for PU. Specifically, Resident #66 was admitted with no PUs. The resident utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity. On 12/10/2021 Resident #66 was identified with a PU to the right heel. The facility staff did not consistently conduct weekly assessments. Timely assessments by the Physician were not completed. Resident #66's was identified with skin impairment and was not referred to the wound care team until 18 days after the PU was first identified. The finding is: The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol dated 2/22/2021 documented the nurse shall describe and document a full assessment of a pressure sore including location, stage, length, width, and depth, and the presence of exudates or necrotic tissue. The Physician will evaluate and document the progress of the wound healing. The facility Prevention of Pressure Ulcer Injuries policy dated 2/22/2021 documented to inspect pressure points which included the heels; and to evaluate, report, and document potential changes of the skin. Resident #66 was admitted with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8, which indicated the resident had moderately impaired cognition. The resident required extensive assistance of one staff member for bed mobility, extensive assistance of two staff members for transfers and was non ambulatory. The resident had no pressure ulcers. A Significant change MDS assessment dated [DATE] documented the resident's BIMS score was 8, which indicated the resident had moderately impaired cognition. The resident had one Stage 3 unhealed pressure ulcer that was not present on admission. A Comprehensive Care Plan (CCP) dated 9/29/2021 documented the resident had the potential for developing pressure ulcers related to [DIAGNOSES REDACTED]. A Physician's admission orders [REDACTED]. A Task List Report (directions to the Certified Nursing Assistant (CNA) for the resident's care needs) dated 9/29/2021 documented to observe skin every shift and to turn and position the resident every two hours. The Certified Nursing Assistant (CNA) Documentation Survey Report (the document where the CNAs sign to indicate care provided) for (MONTH) 2021 revealed from 12/1/2021 thru 12/9/2021 skin observations every shift were not documented for 13 out of 27 nursing shifts. Review of the Nursing Progress Notes from 11/1/2021 through 12/9/2021 had no documentation that Resident #66 had any skin impairment. There was no documented evidence that a Braden scale risk assessment was completed on admission. or at the time the wound was first identified on 12/10/ 2021. A Nursing Progress Note, written by the Registered Nurse (RN) #1, Supervisor, dated 12/10/2021 documented the RN Supervisor was called to the resident's room by the resident's family member to assess Resident #66's right heel for a newly identified open area by the family member. Upon assessment of the right heel a 3. 0 centimeter (cm) round open red area was noted. The Physician was contacted. An order was obtained to treat the area with [MEDICATION NAME], non-stick dressing, dry clean dressing (DCD) twice a day (BID) and to remove the right lower extremity (RLE) brace each shift to check for skin integrity. A podiatry consult was ordered. A physician's orders [REDACTED]. Obtain podiatry consult. The CNA Documentation Survey Report from 12/10/2021 to 12/31/2021 indicated that the skin observations were not documented for 27 of 66 nursing shifts. A Podiatry consult dated 12/14/2021 documented that the resident was seen due to a complaint of pain to the right heel. The Podiatrist documented the resident had a Deep Tissue Injury with [DIAGNOSES REDACTED] (redness) and recommended a wound care consultation. The Physician Monthly note dated 12/21/2021 was blank under the pressure ulcer section of the note. A Wound Report, completed by the Nurse Practitioner (NP) dated 12/27/2021 documented the resident had a right heel Pressure Ulcer with an onset date of 12/10/ 2021. The wound etiology was pressure. The PU measured 0. 5 cm length x 0. 4 cm width x 0. 2 cm depth. The wound was assessed as a Stage 3 PU. The Task List Report was updated on 12/27/2021 to include instructions for a right heel bootie to be worn at all times; and nursing to remove the heel bootie for transfers and skin check every shift. The Task List Report was updated again on 1/21/2022 to include the right foot AFO in place when resident is out of bed and to remove for skin checks every shift. A physician's orders [REDACTED]. Nursing to remove for skin checks, during transfers, for hygiene, every shift. Document refusals and any skin changes. An electronic Weekly Skin observation form completed by the unit nurse dated 12/15/2021 and 12/22/2021 documented the resident's skin was intact. The 12/29/2021 weekly skin observation was blank. The Weekly Skin Evaluation form, completed by the Wound Care Nurse after the wound rounds, dated 1/4/2022 documented Resident #66 had a Deep Tissue Injury to the right heel measuring 1. 4 cm length x 0. 3 cm width x 0. 3 cm depth. A Braden Scale assessment (tool used to determine the pressure ulcer risk) dated 1/4/2022 documented a score of 16 which indicated the resident was low risk for pressure ulcer development. The Physician's monthly Progress note dated 1/18/2022 was blank under the pressure ulcer section of the note. A physician's orders [REDACTED]. Apply [MEDICATION NAME]-soaked gauze pad, followed by padded dry dressing daily and as needed. A physician's orders [REDACTED]. The CCP for potential for developing PUs was updated on 12/10/2021 to include that the resident was noted with a Pressure Injury. On 12/14/21 the wound was assessed as a Deep Tissue Injury by the Podiatrist, on 12/27/21 the wound was assessed as a Stage 3 pressure ulcer, and on 1/25/22 the wound was assessed as a Stage 4. Interventions included but were not limited to apply the right heel bootie to be worn at all times except from transfers, the resident requires the bed as flat as possible to reduce shear, treat pain as per orders prior to treatment/turning to ensure the resident's comfort, vascular consultation per Physician orders, and wound care consult as per the physician's orders [REDACTED]. heel once they took off the resident's right lower extremity brace (AFO). The Incident Report summary documented the possible cause of the open area was due to the resident wearing the AFO brace from home; and with ambulation and transfer mobility rubbing/friction due to increase activities of daily living; and due to paralysis the resident did not feel the pain to site. An observation of the resident's AFO brace was conducted on 2/28/2022 at 3:00 PM with Licensed Practical Nurse (LPN) # 2. The metal screw on the inside of a small opening to the base of the AFO brace was exposed and the canvas like fabric disc that covered the opening was raised and bent, firm to touch and created an uneven surface. The raised disc area appeared to be consistent with the resident's right heel pressure ulcer. The 11:00 PM - 7:00 AM shift CNA #6 was interviewed on 2/28/2022 at 11:01 AM and stated that they have been providing care to Resident #66 for approximately three months and that Resident #66 required extensive assistance of one staff member for care. CNA #6 stated that they only check the resident's skin from the resident's waist to the knees. CNA #6 stated that on their shift the resident wears heel booties only and not the AFO. CNA #6 stated that they do not check the resident's heels on their shift, however, they check to ensure that the resident was wearing the heel booties. The 7:00 AM - 3:00 PM shift Certified Nursing Assistant (CNA #2) was interviewed on 2/28/22 at 11:19 AM and stated that the resident was on their assignment for the last three months. CNA #2 stated that the resident had a brace on one leg and around two weeks after CNA #6 started caring for the resident, CNA #6 noticed there was a dressing on the same leg. CNA #2 stated that they toilet and administer morning care to the resident. However, the resident receives their shower on the 3:00 PM-11:00 PM shift. CNA #2 stated that most morning, at the start of their shift, the resident was out of bed in their wheelchair. CNA #2 stated in the morning they took Resident #66 into the bathroom for morning care and while the resident sat on the toilet, CNA #2 checked the resident's feet then put on the resident's socks and shoes. On 12/10/21 CNA #2 stated before putting on the resident's shoe and sock they checked the resident's heel while the resident was seated on the toilet but did not recall seeing the wound. Registered Nurse (RN #1) was interviewed on 2/28/2022 at 12:17 PM and stated that they recall the day the resident's family member asked them (RN #1) to look at the resident's leg. RN #1 stated when they entered the room the resident was sitting in their wheelchair with the sock and brace removed. RN #1 stated that the wound measured approximately 3. 0 cm, was round and opened, however, there was no drainage present. RN #1 stated they immediately called the Physician and obtained a treatment order and initiated a heel bootie to the right leg. RN #1 stated that heel booties were not in use for the right foot at the time due to the resident utilizing the AFO brace. RN #1 stated they were not sure who was responsible for checking the resident's skin. RN #1 further stated the staff were not aware of the resident's skin impairment until the resident's family member brought the open area of the resident's right heel to the staff's attention. Wound Care LPN #2 was interviewed on 2/28/22 at 2:45 PM and stated that they were first made aware of the wound on the morning of 12/21/2021, however, they had to leave the facility early for personal reasons. LPN #2 stated the resident was first seen on wound rounds by the covering Nurse Practitioner (NP) on 12/27/2021 and that they (LPN#2) first saw the resident's wound on 1/4/ 2022. LPN #2 stated at the time of the initial wound assessment RN #1 should have determined the stage of the PU and should have completed a Braden Scale risk assessment. LPN #2 stated when checking the resident's skin, the CNAs must remove the resident's socks and check their feet. LPN #2 stated that the expectation is that the CNAs remove the resident's socks and shoes and any splint or devices to check the resident's skin. The 3:00 PM-11:00 PM shift CNA #7 was interviewed on 2/28/2022 at 3:13 PM and stated they were assigned to Resident #66 on 12/9/ 2021. The resident required extensive assistance with toileting, and dressing. CNA #7 stated that when they assist the resident with care, they either transfer the resident onto the toilet where they are unable see the resident's heels or they transfer the resident into bed where they are able to see the resident's heels. CNA #7 stated that they could not recall on 12/9/2021, the evening before the wound was identified, if they had placed the resident on the toilet, or into their bed to provide care. CNA #7 further stated that the resident did not complain that their heels hurt during care. The attending Physician was interviewed on 2/28/22 at 3:39 PM and stated that they (Physician) have cared for Resident #66 since 11/1/ 2021. The Physician stated that they did not evaluate the wound and could not recall why an evaluation of the wound was not completed. The Physician stated usually within 48 hours they would have completed an evaluation, however, could not recall the circumstances during that time frame. The Physician stated the expectation is when a new alteration in the resident's skin is identified, that they would be notified by the nurse, and a treatment order is given and within one to two days the wound is evaluated by the attending Physician. The Director of Nursing Services (DNS) was interviewed on 2/28/21 at 4:37 PM and stated that the CNAs were expected to check for any changes in the resident's skin and report any changes to the nurses. The DNS stated when a new pressure ulcer is identified the unit nurse first evaluates the resident's skin then reports their findings to the Registered Nurse Supervisor for assessment of the wound. The DNS stated the resident should have been seen by the wound care nurse as soon as possible on the day of the PU identification. The DNS stated that the AFO device was brought in by the family and should have been checked by the rehabilitation department for appropriate fit. The DNS stated that a Braden scale assessment should have been completed at the time the wound was identified on 12/10/ 2021. The DNS stated a Braden scale risk assessment is completed on admission and when a new wound is identified. The DNS stated the Braden scale assessment dated [DATE] was incorrect because the resident was at high risk for pressure ulcer development due to a [DIAGNOSES REDACTED]. Additionally, the DNS stated that the resident's attending Physician should have assessed the wound soon after notification. The Director of Rehabilitation was interviewed on 2/28/2022 at 5:18 PM and stated that all devices including the AFO are checked for proper function and appropriateness for the resident while in the facility. The Director of Rehabilitation stated that when the resident's family brought Resident #66's AFO to the facility, the AFO was checked by the Rehabilitation department for appropriateness. They stated that the device fit appropriately and there was no damage inside the brace. The Director of Rehabilitation stated they were not made aware Resident #66's AFO was damaged. The Director of Rehabilitation acknowledged that there was no documentation regarding evaluation of Resident #66's AFO by the Rehabilitation department. The Director of Rehabilitation Department stated that the therapist who checked the AFO were expected to document their evaluation of the device. 415. 12(c)(1) | Plan of Correction: ApprovedMarch 28, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I. Immediate Corrective Action for Residents affected: i. One resident was affected by the deficient practice. ii. Resident #17 was assessed by the physician 2/17/2022 after medication administration and resident had no adverse reaction from taking the medication. iii. LPN #1 was educated immediately regarding this practice by the Director of Nursing Services and a medication pass competency was conducted by DNS. iv. Physician order [REDACTED]. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. No other Residents were affected. ii. The Director of Nursing completed an audit to check all residents who are receiving Potassium Chloride tablets to ensure that they are able to tolerate the size of the tablet. No other deficient findings identified. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy titled medication administration was reviewed by DON and no revisions were necessary. ii. All RNs and LPNs will be in-serviced to ensure that potassium tablet as well as other [MEDICATION NAME] coated medications cannot be crushed. An in-service will also be provided for all RNs and LPNs to check medication blister cards for any medication alerts. iii. In-service lesson plan and attendance records will be kept on file for validation. iv. The Pharmacy will add Do Not Crush as part of the instruction in the blister pack for Potassium Chloride tablet. v. A list of medications that cannot be crushed are placed at the nursing station for referrals as needed. vi. A medication pass audit/competency for all RNs and LPNs will be completed by ADNS/Designee. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing or designee will complete a weekly audit x 4 and monthly x3 thereafter to check for accuracy of giving medication. Any negative findings will be corrected immediately. ii. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing/Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2022
Corrected date: April 11, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey completed on 2/28/2022, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (Resident #66) of three residents reviewed for Pressure Ulcer (PU). Specifically, Resident #66 utilized an Ankle Foot Orthosis (AFO) brace to the right lower extremity due to paralysis. On 12/10/21 the resident was identified with an open area to the right heel and there was no documented evidence that the resident's change in skin condition was evaluated or addressed by the attending Physician until 1/7/2022 after the wound had declined to a Stage 3 pressure ulcer. Additionally, there was no documented evidence in the Physician's monthly notes that the progress of the wound was monitored by the attending Physician. The finding is: The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol dated 2/22/2021 documented that during resident visits, the Physician will evaluate and document the progress of the wound healing especially for those with complicated, extensive, or poorly healing wounds. Resident #66 was admitted with [DIAGNOSES REDACTED]. A Significant change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderately impaired cognition. The resident was at risk for developing pressure ulcer, had one Stage III unhealed pressure ulcer that was not present on admission and pressure ulcer reducing device for bed and chair was in place. A Nursing Progress Note, written by the Registered Nurse (RN) #1, Supervisor, dated 12/10/2021 documented the RN supervisor was called to the resident's room by the resident's family member to assess Resident #66's right heel for a newly identified open area by the family member. Upon assessment of the right heel a 3. 0 centimeter (cm) round open red area was noted. The Physician was contacted. An order was obtained to treat the area with [MEDICATION NAME], non-stick dressing, dry clean dressing (DCD) twice a day (BID) and to remove the right lower extremity (RLE) brace each shift to check for skin integrity. A podiatry consult was ordered, and heel booties were in place. The Physician Monthly note dated 12/21/2021 documented there was no clubbing, cyanosis, [MEDICAL CONDITION], venous stasis, [DIAGNOSES REDACTED] to the extremities. The pressure ulcer section of the monthly note was blank. The Physician's monthly Progress note dated 1/18/2022 documented there was no clubbing, cyanosis, [MEDICAL CONDITION], venous stasis, [DIAGNOSES REDACTED] to the extremities. The pressure ulcer section of the monthly note was blank. The attending Physician was interviewed on 2/28/2022 at 3:39 PM and stated that they (Physician) have cared for the resident since 11/1/ 2021. The Physician stated that when a wound is identified nursing staff notifies the Physician and a treatment order is given. The Physician stated if they were in the facility, they would have evaluated the wound at that time and document their assessment in the progress note. The Physician stated that they (Physician) would continue to monitor the wound, however, the Wound Physician sees the resident weekly. The Physician stated during the monthly visits they (Physician) would assess the wound. However, they (Physician) were not sure if they documented their assessment as the wound care Physician is responsible to document weekly. The Physician stated that the first progress note regarding the wound for Resident #66 was documented on 1/7/2022 by them (Physician). The Physician stated that they (Physician) could not recall the circumstances around that time frame. The Physician also stated that their note titled Venous Doppler Study on 1/11/2022 did not include the wound description. The Physician stated the monthly notes dated (12/21/2021 and 1/18/2022) that documented the resident's skin was intact was an oversight. The Physician stated that usually within one to two days they would have evaluated a newly identified wound, however, they could recall why they did not evaluate this resident (#66). The Physician further stated their evaluation should have been documented in the resident's medical record, and that there should have been documentation in the resident's monthly medical note regarding the progress of the wound. The Director of Nursing Services (DNS) was interviewed on 2/28/21 at 4:37 PM and stated that the resident's attending Physician should have assessed the wound soon after notification and documented the assessment in the medical record. 415. 15(b)(1)(i)(ii) | Plan of Correction: ApprovedMarch 29, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I. Immediate Corrective Action for Residents affected: i. One resident was affected by the deficient practice. ii. Resident's #66 wounds were reassessed upon readmission to the facility on [DATE] and there was no change in wound status. iii. CNA #2 and CNA #6 were counseled and educated on the timely completion of skin check by DNS. RN #1 and LPN # 2 no longer work at the facility. iv. The Director of Rehabilitation was educated by the Director of Nursing Services to ensure documentation on braces/splints assessment are completed. v. Wound care physician was terminated. Part II. Identification of other Residents: i. The facility respectfully submits that all Residents could have potentially been affected by this deficient practice. ii. The Director of Nursing or designee will audit all residents with pressure injuries for the primary physician's documentation. All negative findings will be corrected immediately. iii. The Director of Nursing completed a skin assessment of all residents with braces/splints. No negative findings were identified. iv. The Director of Nursing completed an audit on the accuracy of the Braden assessment conducted by RN. No negative findings were identified. v. The ADNS/Designee will audit CNA accountability to ensure skin checks are completed on residents with Braces/splints. Any negative findings will be corrected immediately. vi. The Director of Rehabilitation audited all residents with AFO/braces/splints for proper function, fitting, and documentation in the clinical chart. No negative findings were identified. Part III. Systemic Changes made so the deficiency will not reoccur: i. Policy Titled Prevention of Pressure Ulcer Injuries and the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol were reviewed by DON. No revision were made. ii. All RNs, LPNs, and CNAs will be inserviced on completion and documentation of daily skin checks performed by the CNAs. The CNA Accountability Record will be monitored by the Assistant Administrator or designee. iii. All RNs, LPNs, and CNAs will be in-serviced on wound notifications, observations, and evaluations and above policies. iv. All RNs, LPNs, and CNAs will be in-serviced to ensure body observations/evaluations are completed weekly. v. The Director of Rehabilitation will educate all rehabilitation staff on the evaluation and documentation of all AFO braces brought in by family members prior to resident use. vi. The primary physician will be in-serviced by the Medical Director/designee for timely assessment and evaluation of residents with new skin impairments. vii. In-service lesson plan and attendance records will be kept on file for validation. viii. All residents with pressure injury were re-assessed by wound MD on 3/18/ 2022. iix. Braden assessment for all residents will be completed quarterly. DNS will check for accuracy. ix. The facility has contracted with a new Wound Physician Group to ensure the highest quality of wound care and documentation. Part IV. Monitoring of the Corrective Action/Quality Assurance: i. The Director of Nursing or Designee will complete a weekly audit x 4 then monthly X3 to ensure documentation on all new skin impairments, completion of Braden scale, and CNA skin check documentation. The Director of Nursing or designee will address and correct any negative findings immediately. ii. The Director of Rehabilitation will complete an audit of all residents with AFO devices/splints/braces to check for proper function and documentation in the clinical chart weekly X4 then monthly x 3 months then quarterly thereafter. The Director of Rehabilitation will address and report to the IDT any negative findings immediately. iii. The Medical Director/designee will complete a weekly audit x 4 then monthly audit x 3 months then quarterly of timely physician evaluation and documentation of new wounds. The Medical Director or designee will address and report to the IDT any negative findings immediately. iv. All findings will be reported to the Quality Assurance Performance Improvement Committee monthly for follow-up and recommendation as necessary. Part V. Responsibility/Discipline: Director of Nursing Services/Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2022
Corrected date: June 28, 2022
Citation Details None | Plan of Correction: ApprovedAugust 23, 2022 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. The Medical Director is in agreement there is no additional risk to the residents. 3a. On (MONTH) 1, 2022, the facility's operator contracted with an architectural firm to conduct an FSES. It has been determined by the Architect, that the facility does not meet the requirements to pass the FSES. This is due to the fact that the existing ceiling suspension grid and ceiling tiles are not of a fire rated type and penetrating items such as recessed light fixtures and speakers are not fire protected above the ceiling. Additionally, certain HCAC ceiling diffusers are not protected with fusible link fire dampers. As a result, the building currently has a Construction Type of Type I (000) per NFPA 220. The facility failed the FSES for extinguishment safety on Third Level Zones 3A, 3B and 3C. The facility has applied for a time limited waiver to BAER (Waiver #221W031) for work to be conducted with a completion date of 8/1/2024 (Corrective Action will be completed by 10/1/2023). During the waiver period the facility will modify its existing suspended ceiling systems and components thereby upgrading the existing floor ceiling assemblies to a 2-Hour fire rated assembly throughout the entire building. These upgrades will bring the building into compliance with 19. 1. 6. 1 of NFPA [PHONE NUMBER] by achieving a Construction type of Type II (222) per NFPA 220. 4aThe Overall timeline to correct the issues identified on the FSES report is as follows: a. Evaluation of Deficiency & Recommendation of Corrective Action. Start date: 4/1/ 2022. End Date: 4/1/ 2022. Duration: 0 month. b. Preparation of Contract Documents. Start date: 5/1/ 2022. End Date: 8/1/ 2022. Duration: 3 months. c. Obtaining Local Permits & Approvals (this serves as notification to the Building Authority Having Jurisdiction). Start date: 8/1/ 2022. End Date: 10/1/ 2022. Duration: 2 months. d. Duration of Construction. Start date: 10/1/ 2022. End Date: 10/1/ 2023. Duration: 1 year and 0 months. e. Overall Time Limited Waiver Duration. Start date: 4/1/ 2022. End Date: 10/1/ 2023. Duration: 1 years and 6 months. 4b Detailed Scope and Phasing is as follows: Construction in resident areas will be done during normal business hours 8:00 a.m. ?ö?ç?ú 5:00 p.m., Monday thru Friday. PHASE 1: Simultaneous with Work in Phases 2 and 3 (10-1-2022 to 10-1-2023) Ground Floor: No resident beds on this floor. Replacement of Ceiling Systems in service and maintenance area done simultaneous with upper floors. First floor: No resident beds on this floor. Replacement of Suspended Ceilings in public and administrative area. This work will be done at off hours, no residents will be present during construction in these areas. This work will be done simultaneously with work on the upper floors. Replacement of Suspended Ceiling grid and tiles. Replacement of all recessed lights with lights having fire canopies on the blind side??ÿ of the ceiling and installation of fire dampers at ceiling air diffusers. Replacement of all recessed speakers with fire rated type speakers. In each zone, 3 feet of the 8 foot wide corridor will be segregated by plastic barriers so that continuous egress is maintained in the remaining 5 foot corridor width. No construction materials, tools or debris will be allowed to accumulate in the remaining 5 foot corridor width. Residents will not have access to the work zones. PHASE 2: Second Floor ?ö?ç?ú 10-1-2022 to 4-1-2023 Replacement of Suspended Ceiling grid and tiles. Replacement of all recessed lights with lights having fire canopies on the blind side??ÿ of the ceiling and installation of fire dampers at ceiling air diffusers. Replacement of all recessed speakers with fire rated type speakers. This work will be staged so that only a portion of the overall corridor system will be a work zone??ÿ. In each zone, 3 feet of the 8 foot wide corridor will be segregated by plastic barriers so that continuous egress is maintained in the remaining 5 foot corridor width. No construction materials, tools or debris will be allowed to accumulate in the remaining 5 foot corridor width. Negative pressure exhaust fans with HEPA filtration will be used in work zones to reduce dust. Residents will not have access to the work zones. As only 1 Floor will be renovated at a time, the facility will stage programs and activities in central areas and on other floors to reduce the number of residents on the construction floor??ÿ during construction work hours PHASE 3: Third Floor ?ö?ç?ú 4-1-2023 to 10-1-2023 ?ö?ç?ú No Work in Resident Rooms Replacement of all recessed lights with surface mounted lights and installation of fire dampers at ceiling air diffusers. This work will be staged so that only a portion of the overall corridor system will be a work zone??ÿ. In each zone, 3 feet of the 8 foot wide corridor will be segregated by plastic barriers so that continuous egress is maintained in the remaining 5 foot corridor width. No construction materials, tools or debris will be allowed to accumulate in the remaining 5 foot corridor width. Negative pressure exhaust fans with HEPA filtration will be used in work zones to reduce dust. Residents will not have access to the work zones. As only 1 Floor will be renovated at a time, the facility will stage programs and activities in central areas and on other floors to reduce the number of residents on the construction floor??ÿ during construction work hours. 5. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. additional fire drills (minimum 2 times per month) 2. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 3. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 4. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 5. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required.??ÿ 6. During construction, facility will perform frequent observations of the work areas to monitor resident safety. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. Throughout all phases of this project the facility will use an interdisciplinary approach to ensure resident safety. All facility department heads and staff will be notified in advance of the project phasing and their respective responsibilities. The facility has established Safety Officers to act as a liaison between the facility and the contractor. The Safety Officers will evaluate daily, any safety issues or concerns. All staff in the vicinity of the construction areas will be responsible to monitor the area to ensure that residents are not exposed to any hazards. This includes, nurses, CNA's, housekeeping staff, and recreation staff. In-service education will be provided to staff prior to the commencement of construction as to what their responsibilities will be. In-service will be provided by the facility's In-Service Coordinator, Administrator, Director of Nursing, and Director of Maintenance to ensure that Staff are properly monitoring residents throughout their daily routines. They will be instructed to make frequent rounds of their respective areas approximately every 15 minutes. The existing nurse call system will remain completely operational for the duration of the construction project. 7. Notification of Families and Staff The administrator will hold meetings with residents, families and staff regarding the impending construction and how it will affect their daily routines. 8. Signage Appropriate signage will be utilized to delineate the areas of construction. This will ensure that the residents will remain away from the construction areas. 9. Storage of Materials The contractor will store materials in locked storage rooms located in the construction area and in storage containers outside the facility, adjacent to the parking lot. All combustible materials, cleaning fluids, gases, etc. will be removed from the work area at the end of each day and stored in a fire proof cabinet. The facility safety officer and the project superintendent are responsible to monitor that these items are used and stored properly each day. Any concerns of improper use or storage will be addressed immediately with corrective actions implemented by the safety office and the project superintendent. 10. Fire Safety The Director of Maintenance will ensure that a minimum of four (4) additional fire extinguishers will be available in the construction areas at all times. In the event of a disruption of fire sprinkler and/or smoke detector systems during construction, the facility will implement its fire watch protocol. Means of egress within construction zones??ÿ will be maintained uninterrupted for the duration of the construction. 11. Disposal of Refuse All construction refuse/debris will be properly placed in a refuse dumpster located outside, adjacent to the building. 12a. Administrator, in conjunction with Director of Maintenance, will meet with contractors to ensure timeliness of dates as reflected in the waiver request. 12b. Administrator will report any updates at the next quarterly QA meeting. 13. The Administrator is responsible for the correction of this deficiency. 14. Insuring the Problem does not Recur: Facility will in-service its Senior Management along with the maintenance and housekeeping staffs with regards to the fact that the ceiling systems in the building are fire rated and that they cannot be replaced with non-fire rated systems. Training will also cover the fact the ceilings themselves are part of an overall fire rated assembly which includes the fire protection of penetrating items such as light fixtures, HVAC diffusers, speakers and similar items. Part IV. Monitoring of the Corrective Action/Quality Assurance: The Administrator, in conjunction with Director of Maintenance, will meet with contractors to ensure timeliness of dates as reflected in the waiver request. Administrator will report any updates at the monthly QA meeting. Part V. Responsibility/Discipline: Director of Maintenance Completion Date (X5): 7/11/2022 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2022
Corrected date: April 27, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY 556, NY 055, NY 324) the facility did not ensure a resident's right to be free from abuse for 2 (Resident #1 and Resident #2) out of 4 residents reviewed for abuse. Specifically, on 3/30/2024, Resident #2 was witnessed by 2 certified nurse assistants(Staff #6 and Staff #7) being fondled under their shirt by Resident # 3. Resident #2 was removed from Resident #3's room and Resident #2's shirt was pulled down by the certified nurse assistant. 2) On 4/22/2024, Resident #1 stated that a certified nurse assistant(Staff #1) was grabbing and pulling their right arm roughly while attempting to change their shirt and Resident #1 sustained an ecchymosis to the area.There was no care plan to address potential victim for abuse. Findings include: The facilities Resident Abuse, Neglect, Exploitation or Misappropriation policy statement documented it is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone, including but not limited to, staff, other residents, consultants, volunteers, contractors, and staff from other agencies, family members, legal guardians, resident representatives, friends or other individuals. The policy defines sexual abuse as the non-consenting contact of any kind and includes but is not limited to sexual harassment, sexual coercion or sexual assault. Resident #2 (victim) was admitted to the facility with [DIAGNOSES REDACTED]. A Comprehensive Minimum (MDS) data set [DATE] documented Resident #2 is severely cognitively impaired, the resident wanders significantly daily and wanders into other residents room. Resident #2 required set up assistance for meals, partial/moderate assistance for toileting and supervision for bed mobility and transfers. Resident #2 was always incontinent of bladder and bowel. Review of the accident/incident report dated 3/30/2024 documented Resident #2 was unable to verbalize how the incident occurred. The Accident/Incident report documented 2 certified nurse assistants witnessed Resident #2 in Resident #3's room with Resident #3's hand inside Resident #2's blouse. The investigative summary documented Resident #2 has dementia with poor safety awareness. Resident #2 wanders within the unit. The Accident/Incident report documented Resident #2 with no history of going into other resident's rooms, and that they may have been called into the room by Resident # 3. Resident #2 with no verbalization on how the incident occurred and had no recall of the event due to dementia. Resident #2 had no evidence of emotional distress or psychological effects from the incident. The accident /incident report documented that after thorough investigation, there is cause to believe an alleged resident abuse occurred. Safeguards in place to keep the resident safe and prevent re-occurrence. Resident #3 (pepertrator) was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 13/15, associated with intact cognition. Resident #3 had moderate difficulty hearing and impaired vision. Resident #3 exhibited behavioral symptoms directed towards others and rejected cares, required set up with eating and substantial/maximal assistance with toileting. Resident #3 required partial/moderate assistance with bed mobility and transfers and was frequently incontinent of urine and occasionally incontinent of bowel. Review of the accident/incident report dated 3/30/2024 documented Resident #3 was observed by staff with their hand inside Resident #2's blouse in their room. The investigative summary documented Resident #3 had sexually inappropriate behavior towards staff and others and usually kept to their room and did not congregate with other residents. The accident/incident report documented Resident #2 wanders on the unit and had no history of going into other resident's rooms. Most likely Resident #3 called Resident #2 into their room. Resident #3 was observed with their hand inside Resident #2's blouse and when confronted by staff, Resident #3 pulled their hand away and denied doing anything wrong. Resident #3 refused to be moved off the unit, police were called in to assist and Resident #3 then complied. Resident #3 then complained of pain despite pain medications being given and demanded to be sent to the hospital. Resident #3 was sent to the emergency room for a psychiatric and pain evaluation. The investigation concluded that there was cause to believe an alleged resident abuse occurred. Immediate safeguards were put in place to keep Resident #2 and other residents safe and prevent re-occurrence. During an interview on 5/7/2024 at 2:05 PM with the Director of Social Services, they stated Resident #3 was sexually inappropriate with Resident # 2. They stated Resident #3 was observed by staff putting their hands under Resident #2's shirt. The Director of Social Services stated Resident #2 is very confused and non-verbal and could not verbalize what occurred. The Director of Social Services stated they did not enter a note regarding the incident with Resident #2 in their medical record. During an interview on 5/8/2024 at 10:15 AM the Assistant Director of Nursing, they stated they were informed of the incident that occurred on 3/30/2024 by the Nursing Supervisor who notified them that 2 staff members reported they saw Resident #3 with their hand up Resident #2's shirt. The Assistant Director of Nursing stated they told the nursing supervisor to notify the residents families, the physician, and the Director of Nursing. The Assistant Director of Nursing stated they also instructed the Nursing Supervisor to remove Resident #3 from the unit. The Assistant Director of Nursing Stated Resident #3 had attempted to kiss another resident prior to this incident. The Assistant Director of Nursing stated the supervisor called back and to informed them that Resident #3 refused to move off the unit. The Assistant Director of Nursing stated they directed the Nursing Supervisor to notify the police, and upon police arrival, Resident #3 was escorted from their room on another unit. Stated the incident was witnessed by Certified Nurse Assistant (staff #6) and certified nurse assistant (staff #7), and that the incident took place in Resident #3's room. The Assistant Director of Nursing stated there is no video of the incident and that they called the Town of Newburgh police department and were informed no report was created, that there is only a log that the police responded to the facility, but no report about the incident was written. During a telephone interview on 5/15/2024 at 1:45 PM certified nurse assistant-witness Staff #7 they stated they recall the incident that occurred on 3/30/2024 with Resident #2 and Resident # 3. Stated they were coming from the day room, closer to the 2 East unit with certified nurse assistant-witness Staff #6 . As they walked past Resident #3's room Staff #6 (certified nurse assistant-witness said what are you doing-stop that. Stated they were about a foot ahead of Staff #6 and they back stepped and saw Resident #3's hand coming from underneath the blouse of Resident # 2. Staff #7 stated they went into Resident #3's room and removed Resident #2 and pulled their shirt down, then reported it to the nurse. Stated the nurse called the supervisor and they were told to do an incident report and write statements. Stated the nurse did a body check on Resident #2 and the resident did not seem to them to be in any distress. Stated Resident #2 was just kind of looking dazed when they removed them from Resident #3's room. Staff #7 stated they asked Resident #3 why they were doing that, and the resident did not respond. Stated Resident #2 wanders a lot and goes into other resident's rooms all the time. Stated staff have to redirect Resident #2 when they see them wandering. Stated if they are assigned to Resident #2, they have to observe them and see what they are doing. Staff #7 stated they have heard about Resident #3 touching resident's before but have not witnessed it before this incident. Stated Resident #3 always has something going on with them and their behaviors, but they are never assigned to them. Stated they have not seen any changes in Resident #2's behavior and they are still always wandering. During a telephone interview on 5/15/2024 at 5:15 PM Staff #6 (certified nurse assistant-witness #1) stated they recall the incident that occurred on 3/30/2024 with Resident #2 and Resident # 3. Stated they were passing Resident #3's room and saw Resident #2 standing in front of Resident #3 and they had their arm under Resident #2's shirt. Stated Resident #3 was moving their hand up and down and in a circular motion under Resident #2's shirt. Staff #6 stated they stopped and said what are you doing and Staff #7 that was with them, went in took Resident #2 out of the room. Stated Resident #3 did not say anything in response and just moved their hand fast from under Resident #2's shirt. Staff #6 stated Resident #2 was just standing there innocently looking at Resident #3 and they did not know what was going on. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] documented Resident #1 minimal difficulty hearing and wears a hearing aid. Documented a BIMS score of 12. Required supervision for eating and bed mobility, dependent for toileting and required substantial/maximal assistance for transfers. No behaviors noted. Documented Resident #1 is frequently incontinent of bladder and bowel. Review of the accident/incident report dated 4/23/2024 documented alleged physical abuse/neglect/mistreatment, a purple discoloration was noted on Resident #1's right forearm, measuring 7. 5 x 2. 5 cm. Resident #1' daughter and the physician were notified of the skin discoloration on 4/23/ 2024. A description of the incident documented Resident #1 alleged that at 3:30 AM a staff member was trying to remove their shirt and was pulling and grabbing their right arm, and had their arm against their body, and they told the staff member to stop because they were hurting them. Resident #1 stated the staff member did not let go of their arm and continued to pull their arm trying to take it out of the sleeve and take their shirt off. Documented Resident #1 was observed with a purple discoloration to their right forearm upon skin assessment measuring at 7. 5 x 2. 5 cm. The Accident/incident report documented the incident occurred in Resident #1's room, the certified nurse assistant involved was trying to remove the shirt sleeve from Resident #1's right arm and was tugging at the sleeve which was tight and snug. The staff was pulling the right arm and firmly held the arm in the process. Stated the resident however indicated that the staff was hurting them and they did not stop to consider this during the undressing process. The investigative conclusion documented it revealed there is cause to believe alleged resident, abuse, mistreatment or neglect/injury of unknown origin/exploitation/misappropriation of resident property after a thorough/ complete investigation regarding the incident has occurred. Immediate safeguards are in place to keep the resident safe and prevent re-occurrence. Review of a progress note dated 4/23/2024 written by the Director of Nursing documented Resident #1 with a 7. 5 cm x 2. 5 cm purple discoloration to the right forearm with no associated swelling or change to range of motion noted. Complained of some light tenderness with touch. Skin is fragile with increased tendency to bruise easily which was also reported by Resident #1's daughter who was notified of the findings and of resident claim that staff on the overnight shift pulled on their arm while trying to take their long sleeve shirt or sweater off to dress them. Documented the physician was notified of the findings and an order was obtained for an x-ray of the right forearm and there was no fracture. Resident #1 was provided reassurance and emotional support and the Administrator was aware. During an interview on 5/7/2024 at 1:15 PM Resident #1 stated their whole forearm was purple from the incident. Stated they did an x-ray of their arm. Resident #1 stated when the certified nurse assistant was taking their blouse off they pulled their arm very hard and they told them to stop, and that they were hurting them, but the certified nurse assistant did it anyway. Stated the facility stated they talked to the person, but they could not explain who they were because of their age and memory not being so good. Stated they were not sure if the certified nurse assistant was dismissed mor not. Stated now when the staff try to remove their shirt, they tell them to wait and let them help. Stated the staff is in a hurry to dress and undress them. Stated they are [AGE] years old. Stated their arm still hurts from the incident. Resident #1 stated they are not sure if the staff member had worked with them again or not because they could not remember what they looked like. The facility told them they were going to dismiss the certified nurse assistant and they do not know if they did. Resident #1 stated they are scared when a new aide takes care of them because they are not sure if they will hurt them. Verbalized again that they are always afraid now when someone comes into their room thinking it is the certified nurse assistant. During an interview at 5/7/2024 at 3:28 PM with Staff #4 (Unit manager-1 West) stated they were informed by Staff #3 (certified nurse assistant) that Resident #1 stated the night shift certified nurse assistant grabbed them and was rough with them and bruised their arm. Stated they did observe a darkened area to Resident #'1's right forearm. Stated Resident #1 did have a discoloration on their arm, but they did not do a full skin assessment of the resident. Stated they did not write a note about the observation either. Staff #4 stated an ecchymosis area classifies as a skin impairment and they should have documented in a progress note that they saw the area on Resident #1's arm and informed the Director of Nursing. Stated the certified nurse assistant does not work with Resident #1 but they are still on the unit 1 West, but that was not their decision. During an interview on 5/7/2024 at 4 PM the Director of Nursing stated they did not substantiate the allegation because the certified nurse assistant stated the bruise was there already, that she had noticed some discoloration prior to that area on Resident #1's forearm. Stated they changed the incident report to state that there was no cause today (5/8/2024), because the initial accident/incident report stated that there was cause to believe abuse occurred. Review of the accident/incident report provided now has all changed documentation stating the incident was not substantiated. The Director of Nursing stated that it was a preliminary report provided initially by accident and they had to modify it based on the final outcome of the investigation. Stated they will be assigning the certified nurse assistant to the other side of the building and that Resident #1 has not verbalized to them or the unit manager of their feelings they verbalized today prior. Stated Resident #1 is still anxious and fearful when they spoke with them and the unit nurse reassured Resident #1 that the certified nurse assistant has not been working with them. During an interview on 5/8/24 at 2:10 PM Staff #3 (certified nurse assistant) stated they went into Resident #1's room and they stated staff were cleaning them, and they pulled their arm, and they were really rough. Staff #3 stated Resident #1 told them what happened, and they stated they were wet, and Staff #1 (certified nurse assistant) was changing their shirt at 3:30 in the morning, they were being rough and pulled their arm. Staff #3 stated Resident #1 usually has on a long sleeve shirt and a little sweater. Staff #3 stated when they were talking with Resident #1 their arm was exposed and they could see the bruise immediately. Staff #3 stated when they took care of Resident #1 the day before the incident (4/21/2024), Resident #1 did not have the bruise on their arm. Staff #3 stated when the resident told them about the incident, they immediately approached the certified nurse assistant and the nurse, and they stated that Resident #1's name band was the cause of the bruise. Stated Resident #1 stated the name band had nothing to do with it. Stated Resident #1 is very anxious since after the incident, reminding them constantly to be careful and gentle with them. Stated the resident did not want to change her shirt after that day. Stated the certified nurse assistant is still working on the unit, but they are not allowed to be on the assignment with Resident # 1. During an interview on 5/8/2024 at 3:55pm with Certified Nursing Assistant (Staff #1), they stated they went into Resident #1's to provide cares. Resident #1's clothing was damp so they proceeded to take their shirt off and when they took off the right sleeve, they heard a pop. Resident #1 stated they hurt them and they replied they were not hurting them. Staff #1 stated they noticed Resident #1 had some discoloration on their right arm and they did not pay attention to the discoloration and did not report the discoloration to anyone. When they left Residnet #1's room, Licensed Practical Nurse(Staff #2) went behind them and thats when they heard Residnet #1 crying. Certified Nurse Assisitant(Staff #1) stated they have not worked with the resident since the incident. They were suspended for 2days and provided a statement to Director of Nursing. 10NYCRR 415. 4(b)(1)(i) | Plan of Correction: N/A Plan of correction not approved or not required |