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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the abbreviated survey (NY 143) the facility did not ensure residents were free from abuse, neglect or mistreatment for 1(Resident #1) of 3 reviewed. Specifically, on 3/5/2025, Registered Nurse Supervisor#1 observed Certified Nurse Aide #1 pushing Resident #1 who is severely cognitively impaired, from the front in the hallway. Resident #1 stumbled backwards but did not fall. Certified Nurse Aide #1 was asked why they pushed the resident, and they responded, because he does not listen. The findings are: The Facility Policy titled Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting last revised on 11/4/2022 documented that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents/clients must not be subjected to abuse by anyone, including , but not limited to staff, other resident/clients, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, friends, students, interns or other individuals. Resident #1 was admitted with [DIAGNOSES REDACTED]. The 12/27/2024 Quarterly Minimum Data Set (MDS) an assessment tool documented that Resident #1 had severe impaired cognition and required supervision with eating, bed mobility, transfers and ambulation. The resident needed moderate assistance with shower/bathing and toileting and had no behaviors or rejection of care. The Abuse Care Plan dated 8/23/2024 and revised on 3/7/2025 documented that Resident #1 was at risk for harm and abuse related to self-directed or other directed, dementia, mood disorders, and [MEDICAL CONDITION]. Interventions included encouraging resident to verbalize cause for aggression, encouraging resident to report any negative interactions. Social work to provide support, supportive counseling. Psychiatry and psychology consultations as deemed necessary. The 3/5/2025 Risk for Abuse care Plan documented that Resident #1 was at risk and a potential victim of abuse as evidenced by primary [DIAGNOSES REDACTED]. Interventions included providing emotional support, and Psychiatric and Psychological evaluations as needed. The Internal Investigation dated 3/11/2025 documented that on 3/5/2025, Registered Nurse Supervisor #1 observed Certified Nurse Aide #1 pushing Resident #1 from the front. Resident #1 wobbled backwards but did not fall. The Registered Nurse Supervisor immediately removed Certified Nurse Aide #1 from Resident #1's care and directed them to the medication room and assessed Resident #1 to ensure that they were not hurt. No visible injuries noted. Certified Nurse Aide #1 was immediately suspended pending investigation. 911 was called. The facility concluded that based on their investigation the allegation of abuse was substantiated because the incident was witnessed by Registered Nurse Supervisor #1, who observed Certified Nurse Aide #1 shoving the resident causing Resident #1 to stumble backwards. The Certified Nurse Aide #1's written statement dated 3/6/2025 documented that while they were watching the other residents around the nurse's station, Resident #1 was flickering the light switch on and off and the other residents were complaining about the light. Certified Nurse Aide #1 documented they went over to Resident #1 and took them by the arm and moved them from the light switch. When Registered Nurse Supervisor #1 observed them touching Resident #1, they asked them why they did that. Certified Nurse Aide #1 documented Resident #1 was annoying the other residents. Attempt to reach Certified Nurse Aide #1 on 3/13/2025 at 11:11 am was unsuccessful. Unable to leave a voicemail. During an interview on 3/13/2025 at 12:23 PM, Registered Nurse Supervisor #1 stated that on 3/5/2025 at approximately 8:10 pm during rounds they were coming from the Weinberg unit facing NE2 unit, and as they pushed the door, they saw Certified Nurse Aide #1 push Resident #1 and the resident stumbled backwards but did not fall. Registered Nurse supervisor #1 stated that they did not observe Resident #1 playing with light switches. Registered Nurse supervisor #1 stated that they went over to Resident #1 to make sure that they were ok. There were no signs of distress observed. Certified Nurse Aide #1 was brought into the medication room and asked about the incident. Certified Nurse Aide #1 stated Resident #1 does not listen. Registered Nurse Supervisor #1 stated that they immediately called the administrator on duty, and they received instructions to send Certified Nurse Aide #1 home. Registered Nurse Supervisor #1 showed surveyor the exact area where the alleged abuse happened which was in front of room [ROOM NUMBER] (linen chute) on unit ne 2. During an interview on 3/13/2025 at 12:45 pm, the Administrator stated that they are no video footage for the incident because there are no cameras in the hallway. Cameras are only located at entrances, exits, the loading dock, the kitchen and basement corridors. During an interview on 3/13/2025 at 12:47 pm, the Director of Nursing stated they received a call from the Assistant Director of Nursing after the incident that Certified Nurse Aide #1 was sent home because they allegedly shoved a resident. The Director of Nursing stated that based on the facility investigation concluded it was abuse because Certified Nurse Aide #1 did not deny that they shoved Resident # 1. The incident was also witnessed. The Director of Nursing stated that they have reached out to the facility lawyers and Certified Nurse Aide #1 will most likely be terminated. The Director of Nursing stated that all facility staff are being educated on abuse and rough handling of residents. During an interview on 3/13/2025 at 5:13 PM, the Director of Nursing stated that they have already drafted up the paperwork for the termination of Certified Nurse Aide #1 and Certified Nurse Aide #1 will not be re hired. 10NYCRR 415. 4(b) | Plan of Correction: ApprovedMarch 28, 2025 1. What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice Resident #1 was assessed immediately to ensure that there were no injuries and emotional support was provided by RN Supervisor. A complete skin check was completed on resident #1 with no abnormal findings. Resident #1 was evaluated by the Social Worker and was unable to recall the incident due to severe cognitive impairment. Resident #1 also did not display any sign or symptoms of emotional distress. A psychology consult was also ordered for Resident #1 who was unable to recall the event and unable to engage in therapeutic interaction. Social worker, has and, will continue to follow up with resident to provide emotional support. Resident #1 was monitored for behavioral changes. No behavioral changes were noted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this deficient practice. The Director of Social Services and or designee will review and update care plans addressing the risk for Abuse for all residents with behavioral and/or cognitive impairment. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure the deficient practice will not recur the Director of Nursing and/or designee will review the policy on Abuse/Neglect/Mistreatment- Prevention, Assessment & Reporting of these or other crimes against a resident/client in our care. Staff training and education will be provided to all staff on Abuse, Mistreatment Prevention. This education will focus on the facility responsibility to protect the resident rights and ensure residents remain from abuse. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur,i.e., what quality assurance program will be put in practice The Director of Nursing and/or will perform random audits a total of five staff interviews weekly x 1 month and then bi-weekly x two weeks ,and then monthly to ensure ongoing compliance. The Director of Social Work will perform random audits a total of five residents interviews weekly x 1 month ,and then bi-weekly x two weeks ,and then monthly to ensure ongoing compliance. All findings will be reported to the QAPI Committee by the Director of Nursing on a monthly basis. |