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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 11, 2025
Corrected date: February 27, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 997) initiated on 2/9/2023 and completed on 2/15/2023, the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, not later than 24 hours, if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the New York State Department of Health (NYSDOH). This was identified for one (Resident #368) of five resident reviewed for Accidents. Specifically, Resident #368 sustained a fractured left humerus that was identified by the facility on 8/9/ 2022. The origin of the injury was unknown. The facility did not report the injury to the NYSDOH until 8/12/ 2022. Additionally, the facility did not include in their report of 8/12/2022 to the NYSDOH that staff caring for Resident #368 were not following the resident's plan of care. The finding is: The facility's policy, titled Abuse Prevention, dated 3/22/2022, documented under the subtitle Reporting, all allegations must be immediately reported to the Administrator, and no later than 24 hours to the state survey agency if the events that caused the allegation do not involve abuse and do not result in a serious bodily injury. The policy did not include protocols for reporting injuries of unknown origin. Resident #368 was admitted with [DIAGNOSES REDACTED]. The 6/1/2022 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total care for Activities of Daily Living (ADLs), including two-person physical assistance for bed mobility. A Comprehensive Care Plan (CCP) titled ADLs-Mobility, Ambulation, Transfers, effective 11/23/2021, and last revised on 8/9/2022, documented to provide two-person extensive assistance for bed mobility. The Resident Nursing Instructions (instructions provided to Certified Nursing Assistants (CNA) regarding resident care needs) as of 8/1/2022, documented the resident was totally dependent on staff for bed mobility, requiring two-person physical assistance. A nursing progress note dated 8/4/2022 documented Resident #368 as having left shoulder swelling, warmth, and tenderness. There was no identified trauma or fall. The physician was notified, and an x-ray was ordered. The x-ray results of the left shoulder were negative for fracture, dislocation, or subluxation. A nursing progress note dated 8/8/2022 documented the resident had ecchymosis (bruising) to left antecubital fossa (inner elbow area), with swelling and tenderness. The physician was notified, and x-rays were ordered. The x-ray revealed an acute to subacute distal humeral (arm) fracture. The resident was transferred to the hospital as per the physician's orders [REDACTED].#368 was admitted to the hospital with [REDACTED].#368's care, going back 48 hours prior to when the shoulder swelling was originally identified on 8/4/ 2022. The A/I report did not identify any fall, trauma, or abuse and the origin of the humerus fracture was unknown. The A/I summary documented that CNAs utilized a draw sheet when turning the resident in bed. The CNAs received disciplinary action and one to one counseling. The A/I report documented that the CNAs were not following the resident's plan of care and were not utilizing two persons for bed mobility. The facility provided evidence of an online submission to the NYSDOH dated 8/12/2022 at 3:34 PM regarding the incident that occurred on 8/4/2022 at 6:30 PM. The case number that was assigned to the submission was NY 555. A review of the intake record for case # NY 555 revealed the incident related to Resident #368 dated 8/4/2022 at 6:30 PM was submitted to the NYSDOH on 8/12/2022 at 3:34 PM. The facility reported that the incident was not the result of a care plan violation, and it was undetermined at the time if there was a reasonable cause to believe that abuse, neglect, or mistreatment occurred. The facility did not include that the CNAs were not following the resident's plan of care and were not utilizing two persons for bed mobility. The Registered Nurse (RN) #1 Risk Manager/Assistant Director of Nursing Services (ADNS) was interviewed on 2/14/2023 at 12:00 PM. RN #1 stated the CNAs who worked alone were given inservice education because Resident #368 was a two-person assist for bed mobility. RN #1 stated the cause of the fractured left humerus was unknown. The A/I dated 8/8/2022 identified that the CNAs were not using two-person assistance for bed mobility to move the resident in bed. RN #1 stated the Director of Nursing Services (DNS) is responsible for reporting incidents to the NYSDOH. The Director of Nursing Services (DNS) was interviewed on 2/14/2023 at 12:15 PM. The DNS stated the CNAs received inservice education because they worked alone, and Resident #368 required two-person assistance for bed mobility. The DNS provided an email that documented the incident was reported to the NYSDOH on 8/12/2022 at 3:34 PM. The DNS stated that during the investigation of Resident #368's injury, it was determined that there was a care plan violation. It was identified that the CNAs did not utilize two-person assistance for bed mobility. The DNS stated this discovery of noncompliance was made on 8/12/2022, and that is when the report was made to the NYSDOH. The DNS stated on 8/9/2022 when the fracture was identified, we knew it was an injury of unknown origin, but we did not suspect any abuse or a crime. The DNS further stated that once the facility identified the care plan violation on 8/12/2022, the incident was reported to the NYSDOH. The Administrator was interviewed on 2/15/2023 at 2:48 PM. The Administrator stated we reported the incident when there was a determination of non-compliance with the care plan. 10NYCRR 415. 4 (b) (1) (ii) | Plan of Correction: ApprovedMarch 28, 2025 No Plan of Correction is required. By copy of this notice received on (MONTH) 25, 2025, from the Metropolitan Area Office, this office is informing the facility Administrator and the CMS of the Immediate Jeopardy findings and Substandard Quality of Care. The facility employed corrective measures prior to the survey that removed the IJ identified on 02/26/ 2025. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance on 2/27/2025 and was in substantial compliance for this specific regulatory requirement at the time of this survey. The facility will continue our training, audits, and QAPI monitoring to ensure this deficient practice will not recur. |