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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 23, 2024
Corrected date: February 14, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews conducted during an abbreviated survey (NY 754, NY 426) the facility did not ensure that each resident was free from abuse for 1 of 4 residents (Resident #1) reviewed for abuse. Specifically, on 7/30/2024 Licensed Practical Nurse #1 was seen on surveillance video picking up a water pitcher with water off their medication cart and throw the pitcher and water in Resident #1's direction. Licensed Practical Nurse #1 then threw a small water bottle at Resident # 1. An assessment of Resident #1 was conducted, and no injuries were identified. Findings include: The facility Abuse, Neglect and Exploitation policy dated 6/1/2021 and last reviewed/revised 10/1/2023 documented it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, causing physical harm, pain or mental anguish includes verbal abuse, physical abuse, and mental abuse. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented Resident #1 had a BIMS score of 15. No behaviors noted. The resident required set up assistance for meals, supervision for bed mobility and required maximal assistance for toileting. The resident had lower extremity impairment on one side, used a wheelchair for locomotion and needed moderate assistance for transfer. Review of a risk for abuse care plan dated 2/21/24 and revised on 5/22/24 documented Resident #1 was at risk for potential abuse related to aggressive behavior. Resident #1 was verbally abusive towards staff and the goal was, Resident #1 will be kept safe and free from abuse through the next review date. Interventions included to create a home like environment as much as possible and encourage diversion activities, refer to psychologist and psychiatrist as needed. Review of a behavior care plan dated 4/24/24 and revised 8/5/24 documented Resident #1 uses abusive verbal language, is resistant to activities for daily living, and exhibits aggressive behaviors. The goal was for Resident #1 to display no negative behaviors through the review date. Interventions included to provide a safe environment, psychological consult and follow up as needed. Review of a behavior symptoms physical abuse care plan dated 6/4/24 documented Resident #1 exhibits physically aggressive behavior towards staff and others. The goal was Resident #1 will show a decrease in the number of episodes of physically aggressive behavior. Interventions included to administer medications as ordered by physician, allow time to de-escalate when agitated, assess/evaluate comfort level and medicate as necessary, document in medical record the intensity, duration or frequency of behavior, notify and report behavior changes to the physician, redirect negative behaviors, , remove from situation triggering behavior and social service evaluation and follow up as needed. A Review of the surveillance video dated 7/30/2024 with no audio was completed during the onsite visit. Resident #1 is seen in the dining room seated around a table with Resident #2 and Resident # 3. Licensed Practical Nurse #1 is seen at the medication cart in the doorway between the dining room and the hallway. Licensed Practical Nurse #1 walked over to Resident #1 and handed them a pill cup with medication. Resident #1 took the medication. There is an inaudible dialogue back and forth between Resident #1 and Licensed Practical Nurse # 1. Resident #1 is seen throwing water from their cup in Licensed Practical Nurse #1's direction, landing on Resident # 3. Licensed Practical Nurse #1 then proceeded to walk towards Resident #1, and the dialogue continues. Licensed Practical Nurse #1 was seen leaning towards Resident #1 and say something. Resident #1 jerked back in their wheelchair at what was said to them and is seen throwing water at Licensed Practical Nurse # 1. Licensed Practical Nurse #1 was seen going to the medication cart, take a bottle of water and fling the water towards Resident #1 and threw the empty bottle at the resident. Licensed Practical Nurse #1 was seen at their medication cart, picking up the water pitcher with water off their medication cart and fling the entire pitcher and water in Resident #1's direction. Licensed Practical Nurse #1 was seen throwing the top of the pitcher in Resident #1's direction. Resident #1 left and headed towards their room. Certified Nurse Assistant #1 appears on the scene and is seen speaking to Resident #1 as they enter their room. Licensed Practical Nurse #1 is seen exiting the video. Review of Accident/Incident Report dated 7/30/2024 documented the incident that occurred on 7/30/2024 at 6:00 PM. Licensed Practical Nurse #1 threw water and a small plastic water bottle at Resident # 1 after Resident # 1 threw water at Licensed Practical Nurse # 1. Resident #1 with no injury noted at the time of the incident. Physician notified at 6:30 PM. Licensed Practical Nurse # 1 was terminated to prevent recurrence. Review of a Resident #2' s (witness) statement dated 7/30/2024 documented they saw Licensed Practical Nurse #1 and Resident #1 throwing water at each other. The statement documented the incident got more intense and the anger intensified, and Licensed Practical Nurse #1 threw the pitcher at Resident #1, and it broke. Resident #1 also threw water at the Licensed Practical Nurse. Resident #3 had hearing impairment and was not interview able. Review of Registered Nurse Supervisor #1's note dated 7/30/2024 at 9PM documented Resident #1 stated they did not sustain any injury from the confrontation. However, Resident #1 stated they felt very anxious and nervous as a result. Therapeutic communication was applied to calm Resident #1 and assure them of their safety. The Incident/Accident report conclusion dated 8/1/2024 documented statements were obtained from all residents present at the time of the incident as well as staff assigned to the unit. Video of the incident was obtained from the facility camera system. After review of the statements and video, the facility concluded the complaint was verified, the employee was immediately terminated, a professional discipline complaint form was filed by the facility with New York State office of the professions. During an interview on 8/6/2024 at 12:24PM Resident #1 stated they have been in the facility for 5 years. Stated they were due for a pain medication, and they asked Licensed Practical Nurse #1 for it, and they stated they were not ready to give it to them yet. Stated Licensed Practical Nurse #1 came and spoke with Resident #2 and Resident #3 and was giving them their pain medications which they are not supposed to get until bedtime, and it was about 6:00 PM. Resident #1 stated they then told Licensed Practical Nurse #1 that they cannot do that, and they stated, do not tell them what to do, I do what I want. Licensed Practical Nurse #1 got in their face and stated, they do what they want to do [***] faggot and if they want to give others their medications now, they will, and Resident #1 will wait. Resident #1 stated they had a little cup of water, and they threw it at Licensed Practical Nurse # 1. Resident #1 stated Licensed Practical Nurse #1 then went back to their medication cart and grabbed the water pitcher and threw it at Resident #1 and it shattered against the wall and broke into pieces. Resident #1 stated they had a little water bottle on the table in front of them and they threw that at Licensed Practical Nurse #1 and Licensed Practical Nurse #1 started charging towards them and the certified nurse assistant held Licensed Practical Nurse #1 back and told them to go back to their room. Resident #1 stated they were scared and shaking. Resident #1 stated Licensed Practical Nurse #1 lost it and was out of control. Resident #1 stated Licensed Practical Nurse #1 told them they do not need this job and that they will kill Resident #1, and you could see it in their eyes. Resident #1 stated they have had arguments with staff prior, but no one had ever threatened them before. Resident #1 stated they were very nervous following the incident and they felt as if they could not defend themself in the wheelchair. they would kill them, and they believed it and could see it in their eyes. During an interview on 8/6/2024 at 1:20 PM, the Administrator stated they were informed about the incident on 7/30/ 24. They reviewed the surveillance video and Resident #1 pushed Licensed Practical Nurse #1's buttons and they lost it. Licensed Practical Nurse #1 exited the building, and they could not speak with them. The Administrator stated they tried to contact Licensed Practical Nurse #1 via telephone but have not been to reach them. The Administrator Stated Licensed Practical Nurse #1 was an agency employee who started in the facility on 7/25/ 2024. The day of the incident was Licensed Practical Nurse #1's first day on the floor and they had only worked 3 shifts prior. During a telephone interview on 8/6/2024 at 2:10 PM Licensed Practical Nurse #1 stated they had only been working in the facility for a couple of days and it was their first time on the unit. Licensed Practical Nurse #1 stated they were switched from the south side to work on the north side where Resident #1 resides. Resident #1 asked them for their pain medication. Licensed Practical Nurse #1 stated the outgoing nurse reported that d just given Resident #1 their medication at 3:00 PM and they informed Resident #1 of that. Resident #1 stated they can have the medication 1 hour early, and they informed Resident #1 that it does not apply to nonscheduled (as needed) medications. Resident #1 was told that the last time they were given the pain medication was at 3:00 PM and when they could only receive their medication at 6PM. Licensed Practical Nurse #1 stated Resident #1 stated Resident #1 called them a piece of[***]because they will not give them their meds before the due time. Other nurses on the unit told them they do not deal with Resident #1 and that no one does. Licensed Practical Nurse #1 stated Resident #1 stated insisted to be given their medication when they were administering medications to other residents. Licensed Practical Nurse #1 stated Resident #1 started to try to stand up, and they stepped away from Resident #1 towards their cart. Resident #1 continued talking while they administered medications to others. Licensed Practical Nurse #1 stated Resident #1 had a pitcher of water and they spit in the pitcher and threw it at them. Licensed Practical Nurse #1 stated they had a pitcher of water and threw it back at Resident # 1. Licensed Practical Nurse #1 stated they engaged in the back and forth with Resident #. For Resident #1 to spit in the water and throw it at them triggered them. During an interview on 8/7/2024 at 5:00 PM, Resident #2 stated they have been in the facility for a year. Resident #2 stated they were in their room, and they heard screaming and cursing. They went out and saw Licensed Practical Nurse #1 in Resident #1's face. Resident #2 stated Licensed Practical Nurse #1 stated they do not need this [***] ing job and they would kill Resident # 1. Resident #2 stated Licensed Practical Nurse #1 went and got their water pitcher and threw it at Resident #1 and some of the water got on them. Resident #2 stated Resident #1 wanted their medications and they did not want to wait for it. Resident #1 saw Licensed Practical Nurse #1 give them their medications and Resident #1 asked why Resident #2 is receiving their meds and not them. Licensed Practical Nurse #1 told Resident #1 it was not time for their medications. Resident #2 stated the facility has a lot of new staff. Resident #2 stated Resident #1 is always in excruciating pain and they get irate at times. Stated Resident #1 cries like a baby at times asking for her pain med and the nurses will tell them, you have 3 minutes left before you can receive your medications. 10NYCRR 415. 4(b)(1)(i) | Plan of Correction: ApprovedJanuary 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was identified as being directly affected by the alleged gap in practice. The facility did not ensure that pain management is provided to resident who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. - An investigation was conducted and concluded that there was no evidence to support that abuse, neglect or mistreatment may have occurred. - Resident #1 was transferred to the hospital on [DATE] and readmitted to Kings Harbor on 2/15/ 24. - Upon resident #1 readmission from the hospital: - A Pain Assessment was completed - Resident #1 was evaluated by PMD and Tylenol 325mg q 6 hours for 14 days was ordered for pain management. - Care Pan #131A Pain Management was updated. - Resident #1 was monitored for pain and the effectiveness of pain management. - LPN #1 was educated on medication administration and documentation. - RN #1 was educated on pain assessment, pain management and updating Care Plan when change in resident condition is noted. - CNAs, LPNs and RNs of the Manor service were educated on reporting new onset of pain and deferring transfer/movement of resident prior to assessment by RN. 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? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All residents with new onset of pain in the last 30 days will be reviewed by the RNM/RNS to ensure that a pain assessment is conducted, PMD was notified, appropriate pain management was implemented, and pain care plan was updated. In the event that non-compliance was identified, it will be immediately corrected to comply with F 697. Responsible Party: RNM/RNS 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? An Ad Hoc QA/PI Meeting with the Administrator, DON, Medical Director, Director of QA/PI, and Staff Development was held to discuss the systemic changes that will be made to ensure that the deficient practice does not occur. 1. The Policy and Procedure for Pain Assessment, Education and Management was reviewed to assure compliance with F697 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and revised accordingly. The change in policy include Pain assessment and Pain Management care plan update shall be performed:??ΓΏ a. On admission/re-admission b. Quarterly and Annually for CCP Meeting c. Upon significant change in residents' condition d. Upon any incident or accident as part of the assessment of the resident e. For any new complaint of pain identified by resident or staff f. Prior to initiation of a pain medication regime or change in pain medication regime g. Upon a change in the resident's pain medication h. At any other time based on nursing or physician assessment Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all RNs and LPNs on pain assessment, management and care plan update. Highlights of the lesson plan include: - It is the policy of Kings Harbor to assess and manage resident's pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. - When and how to perform pain assessment - Communicating with the medical provider when pain is identified - Documentation of pain assessment and management - Updating pain care plan as indicated in the Pain policy Responsible Party: Inservice Coordinator/Designee 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility's compliance with ensuring that all residents with new onset of pain are assessed and managed and that all appropriate documentations are completed. Responsible Party: QA/PI 2. All residents with new onset of pain will be reviewed to ensure that they are assessed, and appropriate management is implemented weekly x 4 weeks and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Nursing Team Leaders/ADON 3. The results of the pain audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the pain audit will be presented and discussed at the facility monthly by QA/PI. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 21, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator. |