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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
Corrected date: February 5, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY 767), the facility failed to protect the resident's right to be free from physical abuse by a nursing home staff. This was evident for one out of seven residents (Resident #4) sampled for abuse. Specifically, on 12/30/2023 at 2:44 AM, the facility's surveillance video recording showed Certified Nursing Assistant #2 roughly pulling some incontinent briefs away from Resident #4 who was sitting in their wheelchair in the hallway. Nurse Supervisor #2 assessed Resident #4 who did not sustain any visible injuries nor complained of pain. The findings are: The facility Policy and Procedure for Prevention/Identification and Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property was last updated on 11/11/ 2022. The policy states that residents must not be subjected to abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property by anyone, including, but not limited to facility staff. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #4 had intact cognition. An Abuse Care Plan for Resident #4 was implemented on 05/26/ 2022. The interventions include to assess Resident #4 for signs/symptoms of abuse, neglect, bruises, and behavior, and to report to appropriate resources. The care plan was updated post incident of 12/30/2023 with additional interventions. The facility surveillance video camera recording dated 12/30/2023 at 2:44 AM was reviewed with the Director of Nursing on 10/08/ 2024. The video recording is blurry. The surveillance recording showed the following: At 2:43:49 AM, Resident #4 wheeled themself down the hallway to a linen cart stationed in the hallway. At 2:44: AM, Resident #4 removed items (identified as incontinent briefs) from the linen cart. Resident #4 was in the process of wheeling themself away from the linen cart but was stopped by Certified Nursing Assistant # 2. Certified Nursing Assistant #2 could be seen on the camera roughly trying to pull the incontinent briefs away from Resident #4 and Resident #4 was pulling back/while holding on to the incontinent briefs. At 2:44:19 AM, Resident #4 was wheeling themself up the hallway. Certified Nursing Assistant #2, who was holding multiple brown incontinent briefs in their hand, caught up/stopped Resident # 4. At 2:45:01 AM, Certified Nursing Assistant #2 attempted to hand Resident #4 the brown incontinent briefs which Resident #4 was refusing. Certified Nursing Assistant #2 observed struggling to pull the blue incontinent briefs away from Resident # 4. Certified Nursing Assistant #2 was also holding onto Resident 4's arm with their (Certified Nursing Assistant #2) left hand while using their right hand to roughly pull the incontinent briefs away from Resident # 4. At 2:45:44 AM, Certified Nursing Assistant #2 was able to pull the incontinent brief away from Resident #4 and walked away leaving two incontinent briefs on the floor. At 2:45:52 AM, Certified Nursing Assistant #3 appeared in front of Resident #4 and was talking to Resident # 4. Certified Nursing Assistant #3 picked up the incontinent briefs off the floor and wheeled Resident #4 away from the area and out of camera's view. The facility Incident Investigation report dated 12/30/2023 documented that Resident #4 reported that Certified Nursing Assistant #2 took an incontinent brief away from them. Resident #4 also reported wanting to push Certified Nursing Assistant #2 to the floor but did not. Resident #4 also reported feeling upset. Resident #4 was assessed with [REDACTED]. Certified Nursing Assistant #2 was removed from the unit. Several residents were interviewed, and all stated they had no issues with Certified Nursing Assistant # 2. The Director of Nursing and the Administrator were immediately notified. The facility's investigation concluded that Certified Nursing Assistant #2's hands, had physical contact with Resident #4's arm. The investigation also concluded that the outcome of the investigation is inconclusive. The police were contacted, and two Police Officers reported to the facility on [DATE] (badge numbers are documented in the incident report). A Nursing progress note dated 12/30/2023 at 8:25 AM, written by Licensed Practical Nurse #1, documented at around 3:10 AM, Certified Nurse Assistant #2 reported that Resident #4 was upset because the incontinent brief was taken away. There were no visible injury or openings observed on Resident # 4. Resident #4 was upset upon entry into Resident #4's room. Resident #4 was assessed at their bedside by the Nursing Supervisor who was called. Multiple attempts were made to contact Certified Nursing Assistant #2 but was unsuccessful. Certified Nursing Assistant #2 resigned from the facility. A certified letter was mailed out to Certified Nursing Assistant # 2. Awaiting response. Certified Nurse Assistant #2 submitted a written statement to the facility dated 12/30/ 2023. The statement documented that they are not allowed to leave briefs into the rooms, so when Resident #4 took all the briefs from the cart, they told Resident #4 to take two and Resident #4 said no. the statement documents that Certified Nursing Assistant #2 told Resident #4 that they will need the briefs back and Resident #4 said no. It is documented that Certified Nursing Assistant #2 tried to take the briefs away from Resident #4 and Resident #4 refused to give back the briefs. Certified Nursing Assistant #2 left Resident #4 with the briefs and Resident #4 took the briefs back to their room. Resident #4 was not on Certified Nursing Assistant #2's assignment. Certified Nursing Assistant #3 provided an undated written statement to the facility. The statement documents that on 12/30/2023 at around 3:10 AM, they heard someone screaming for help. The statement documents that they observed Certified Nursing Assistant #2 and Resident #4 in the hallway and Resident #4 was crying. Resident #4 reported that they went to the cart to get a brief and Certified Nursing Assistant #2 took the briefs away from them. Certified Nursing Assistant #3 took Resident #4 to their room and reported to the nurse (Licensed Practical Nurse #1). During a telephone interview on 10/10/2024 at 10:41 AM, Licensed Practical Nurse # 1, stated that they do not recall Resident #4 and ended the interview. Licensed Practical Nurse #1 provided the facility with a written statement dated 12/30/ 2023. The statement documents that when Licensed Practical Nurse #1 returned to the unit, Resident #4 reported to Licensed Practical Nurse #1 that they are mad because Certified Nursing Assistant #2 took the brief away from them. Resident #4 was anxious and stated that they needed something, maybe [MEDICATION NAME] (a pain medication). Nursing Supervisor #1 was notified. Resident #4 continued to verbalize that Certified Nursing Assistant #2 snatched the brief away from them. Multiple attempts were made to contact Nursing Supervisor #1 but was unsuccessful. Nursing Supervisor #1 provided a written statement to the facility dated 12/30/ 2023. The statement documented that Resident #4 was observed lying in bed alert and oriented times three. Resident #4 reported that they went to take a brief from the cart and Certified Nursing Assistant #2 hold my forearm and took the brief away from them. Resident #4 also stated that they wanted to push Certified Nursing Assistant #4 to the floor. Resident #4 was assessed with [REDACTED]. During a face-to-face interview on 10/09/2024 at 11:40 AM, the Director of Nursing, stated the incident occurred at around 2:44 AM on 12/30/ 2023. The Director of Nursing stated Resident #4 wheeled themself down the hallway to the linen cart and took multiple brown and green incontinent briefs from the linen cart and proceeding to go back to their room. The Director of Nursing stated that Certified Nurse Assistant #2 came up from behind and started to grab the incontinent briefs from Resident # 4. The Director of Nursing stated that while Certified Nursing Assistant #2 was grabbing the incontinent briefs out of Resident #4's hands, Certified Nurse Assistant #2 also grabbed Resident #4's right forearm. The Director of Nursing stated that they reviewed the video surveillance recording and investigated the incident. The Director of Nursing stated Certified Nursing Assistant #2 was called back to view the video recording and after Certified Nurse Assistant #2 was shown the video, Certified Nursing Assistant #2 immediately resigned. The Director of Nursing stated the investigation was inconclusive for abuse. 10 NYCRR 415. 4(b)(1)(i) | Plan of Correction: ApprovedJanuary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #1 was discharged on [DATE] and has since passed away a. Resident #2 had a room/floor change after incident occurred. Resident #2's care plan has been reviewed and found to be appropriate. a psychosocial evaluation has been completed by social work and resident doe snot even re- call the incident. b. No further incidents have occurred. II. All wandering residents who lack capacity have the potential to be affected by this deficiency. a. A 100% audit of current residents who lack capacity, that may be displaying behaviors (handholding, arms around each other, seating preferences etc.) will be conducted. Any concerns will be brought to the IDT and the behaviors and potential relationship will be reviewed and interventions will be care planned as appropriate. III. Facility policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021 and Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022 have been reviewed, and found to be appropriate. a. A monthly relationship meeting??ÿ will be held to include Administrator, DON, Social Work and the Dementia Unit Manager/Designee to discuss/identify any residents that may be displaying behaviors that could suggest a developing relationship between residents. The Unit Manager/Designee will be the chairperson/spokesperson for all nursing employees assigned to the unit. Care plans and further interventions updated as indicated. b. All nursing staff will be educated on the establishment of the 4th floor relationship meeting??ÿ. c. All nursing staff will be educated on identification and reporting any residents who are displaying behaviors such as (hand holding, arms around each other, seating preference, etc.). d. Any staff reports related to the identification of the potential for resident relationship development will be reported immediately to their immediate supervisor. Nursing Supervisory staff will be educated to begin the process of convening the IDT to audit the circumstance of this relationship to include resident capacity, family and MD notification and care plan review. IV. Any changes in behavior or adverse interactions will be reported immediately to DON/Administrator or designee and brought to morning report daily for review and QAPI monthly. a. Administrator will audit the monthly relationship meetings to ensure completion and follow through monthly x 3 months, then quarterly thereafter. b. At monthly QAPI the Administrator will review the results of the monthly relationship meeting and any other reported occurrences of potential relationships developing. V. The administrator is responsible for this plan. |