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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 26, 2024
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 797, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident in one out six residents (Resident #1) sampled. Specifically, Resident #1 was observed on the floor in their room next to their bed at approximately 8:00 PM on 12/02/2024 by Certified Nursing Assistant # 1. A Nursing Progress Note, by Registered Nurse #1, dated 12/02/2024 at 8:18 PM documented Resident #1 was assessed with [REDACTED]. 0. 5 centimeter, and minimal bleeding below the right eye. The Hospital Discharge Summary dated 12/05/2024 documented Resident #1 had a laceration to their right maxillary process for which derma bond was applied. Resident #1's medical record revealed Resident #1 was observed on the floor in their room on 02/08/2024, 03/11/2024, 08/01/2024, and 12/02/ 2024. The Care Plan dated 02/08/2024 documented purposeful rounding every 2 hours and as needed. Resident #1 remained on two hours monitoring from 03/11/2024 through 12/02/ 2024. The findings include: The facility's Policy and Procedure titled Fall Reduction and Injury Prevention Program dated 06/27/2024 documented it is the policy of this facility to take appropriate measures to provide a safe environment and minimize the risk of resident injuries resulting from a fall. All residents will be assessed and reassessed to determine their risk for a fall. Based on the assessment findings, an individualized plan of care is developed, revised, or modified to reduce the risk of falls and falls with injuries. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 09/11/2024 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 03 associated with severe impairment. An Actual Fall Care Plan dated 02/08/2024 at 2:40 PM documented Resident #1 was observed sitting on the floor close to their bed. The interventions documented monitoring for pain and discomfort, and purposeful rounding every 2 hours and as needed. The updated Fall Care Plan dated 03/11/2024 at 7:45 AM documented Resident #1's roommate notified staff that Resident #1 fell while they were trying to get out of the bed. The interventions documented call bell within reach and to remind the resident to use call bell. Transfer Resident #1 closer to the nursing station. The updated Fall Care Plan dated 08/01/2024 documented Resident #1 was observed sitting on the floor next to their bed at 7:20 PM. The interventions documented movie Resident #1 to another room with less air conditioner use. The updated Fall Care Plan dated 12/03/2024 documented Resident #1 had a fall on 12/02/2024 (no time documented). The interventions documented Resident #1 to be transferred to the memory unit for residents with Dementia. There was no documented evidence of monitoring modification to care plans dated 03/11/2024, 08/01/2024, and 12/03/ 2024. A Documentation Survey Report (for Certified Nursing Assistants) dated from 10/01/2024 to 12/02/2024 documented purposeful rounding was being conducted every 2 hours while Resident #1 was awake. There was no documented evidence of monitoring modification on the Documentation Survey Report. A Nursing Progress note dated 12/02/2024 at 8:18 PM, by Registered Nurse #1, documented Certified Nursing Assistant #1 informed them Resident #1 fell on the ground. Resident #1 was noted with a bruise around their right eye and a skin abrasion (about 0. 5cm) with minimal bleeding below the right eye. The Medical Doctor was notified and ordered for Resident #1 to be transferred to the hospital. An Unwitnessed Fall Report (Incident) and Summary of Report dated 12/02/2024 at 8:00 PM documented at around 8:00 PM Certified Nursing Assistant #1 reported Resident #1 was found lying on the floor in a supine position next to their bed. Body assessment revealed a bruise around Resident #1's right eye and a skin abrasion with minimal bleeding below the right eye. Resident #1 was transferred to the hospital. The investigation concluded that neglect did not occur. During an interview on 12/09/2024 at 1:00 PM, Certified Nursing Assistant #2 stated they were assigned to Resident #1 on 12/02/2024 from 3:00 PM - 11:00 PM. Certified Nursing Assistant #2 stated at approximately 7:00 PM Certified Nursing Assistant #1 assisted them in providing care to Resident # 1. Certified Nursing Assistant #2 stated before leaving Resident #1's room, they positioned Resident #1 in the middle of the bed, call bell within reach, and the bed in the lowest position. Certified Nursing Assistant #2 stated 30 minutes after leaving Resident #1's room, they were informed by another staff member (don't recall name) Resident #1 was not in their bed. Certified Nursing Assistant #2 stated they went to Resident #1's room and observed Resident #1 on the floor next to their bed. Certified Nursing Assistant #2 stated Resident #1 was on the floor on the side of the bed away from the door. During an interview on 12/10/2024 at 11:16 AM, Registered Nurse #1 stated while they were making rounds on 12/02/2024 on the 3:00 PM to 11:00 PM (don't recall exact time), they did not see Resident #1 in their bed and asked Certified Nursing Assistant #1 for Resident # 1. Registered Nurse #1 stated Certified Nursing Assistant #1 went to Resident #1's room and observed Resident #1 on the floor. Registered Nurse #1 stated they conducted a body assessment and Resident #1 was observed with a skin abrasion below their right eye. Registered Nurse #1 stated they notified the Medical Doctor who ordered Resident #1 to be transferred to the hospital for further evaluation. During an interview on 12/10/2024 at 2:53 PM, Medical Doctor #1 stated they and Resident #1 speak the same language (Hindi). Medical Doctor #1 stated Resident #1 has severe cognitive impairment/Dementia and that they encouraged Resident #1 to stay in bed to prevent them from falling and Resident #1 said they did not fall. Medical Doctor #1 stated Resident #1 has short-term memory problems and easily forgets. Medical Doctor #1 stated, Resident #1 was transferred to the memory unit where there are more activities to keep Resident #1 engaged. During an interview on 12/11/2024 at 12:00 PM, Associate Director of Nursing #1 stated Resident #1 was being monitored every 2 hours at the time of the fall. Associate Director of Nursing #1 stated Registered Nurse #1 was on duty at the time of the incident and updated Resident #1's care plan. Associate Director of Nursing stated modification to the monitoring should have been updated to 30 minutes, but it was not done. 10NYCRR 415. 12(h)(1) | Plan of Correction: ApprovedJanuary 21, 2025 What corrective actions(s) will be accomplished for the resident found to have been affected by the deficient practice? I. The following actions were accomplished for those residents found to have been affected by the deficient practice: The affected residents (Resident #1) care plan was modified/updated to include monitoring q30 minutes. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: The facility will conduct a review of residents with a history of two or more falls over the past six months to identify those who may require more frequent monitoring to minimize the risk for falls. DNS or designees will conduct an audit on residents who have a history of two or more falls in the past six months. The audit will ensure that a new fall risk evaluation is completed, and that the care plan is revised and updated to reflect modifications to frequency of monitoring, if applicable. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur; III. The following system changes will be implemented to ensure that the deficient practice does not recur: The facility's policy and procedure PC67, titled Fall Reduction and Injury Prevention Program, has been reviewed. It has been determined that no revisions are necessary at this time. All active nursing staff will be re-in-serviced on the Fall Prevention policy by the Nursing Educator(s). All active licensed registered nursing staff will be re-educated on updating residents plans of care to include modifications in monitoring frequency, as applicable. An audit tool has been developed to systematically monitor the completion of post-fall risk evaluations, updates to care plans, and, where applicable, modifications to the monitoring frequency. How the corrective actions(s) will be monitored to ensure deficient practice will not recur, i.e., what quality assurance program will be put into practice IV. The facilitys compliance will be monitored utilizing the following quality assurance system: DNS or designee will report assessment results for residents who have a history of two or more falls in the past six months to the Quality Assurance Performance Improvement (QAPI) committee to ensure compliance with post-fall assessments, care plans, and monitoring. The completion of staff education and compliance with post-fall assessments, care plans, and monitoring will be reported to the Quality Assurance Performance Improvement (QAPI) committee weekly for one month and then monthly for three months, or until compliance is achieved. Responsible Person: Yves Pascal, Director of Nursing |