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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: March 11, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an abbreviated survey (NY 527) conducted, the facility did not ensure that a resident (Resident #1) was free from abuse. This was evident for one (1) of three (3) residents reviewed for abuse. Specifically, on 2/26/2025 at 5:00 PM video surveillance recorded Licensed Practical Nurse #1 abusing Resident #1, who is cognitively impaired, during a medication administration. Licensed Practical Nurse #1 is seen forcefully tilting the resident's head back and holding the resident's nose, while shoving a spoon in their mouth. Licensed Practical Nurse #1 was also seen kicking the back large wheel of the wheelchair that the resident was sitting in and pushing the wheelchair against a table, locking it in position. This resulted in no actual harm that posed an Immediate Jeopardy past non-compliance for Resident # 1. The findings are: Resident # 1 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a minimum data set assessment (an assessment tool) on 1/13/2025 that indicated that they were not cognitively intact. Resident #1 had an abuse care plan in place initiated on 11/23/2024 and updated on 2/28/ 2025. The care plan documented the goal is to ensure the safety, proper care and welfare of every resident in a therapeutic environment. Staff will be knowledgeable of abuse prevention and prohibition and reporting. Review of video surveillance revealed that Resident #1 was in the dining room sitting apart from others at a table alone in the middle of the room. There is no sound to the video. The video is dated 2/26/2025 with a time stamp of 5:00 PM. The title is Dayroom Right and at 0. 19 seconds Resident #1 is seen interacting with Certified Nurse Aide #1 who had just placed a food tray in front of the resident. Licensed Practical Nurse #1 walked towards the table with what appears to be medication. At time stamp 0. 22 seconds Licensed Practical Nurse #1 was giving what appears to be medications to Resident # 1. At time stamp 0. 32 seconds Resident #1 takes a sip of a beverage, at time stamp 0. 43 seconds Licensed Practical Nurse #1 is partially blocking the view but can be seen attempting to give the resident more medication. At time stamp 52 seconds Licensed Practical Nurse #1 tilted the resident's head back and held the resident's nose. The resident spit out a substance onto Certified Nurse Aide # 1. Licensed Practical Nurse # 1 left the room. At time stamp 2 minutes and 11 seconds Certified Nurse Aide #1 left the immediate area near the resident. At time stamp 2 minutes and 24 seconds Licensed Practical Nurse #1 returned to the room and was seen pushing/shoving the back of Resident #1's head. Licensed Practical Nurse #1was seen kicking the back large wheel of the wheelchair, at time stamp 2 minutes and 17 seconds Licensed Practical Nurse #1 shoved Resident #1 wheelchair up against the table and locked the wheelchair in place while the resident was sitting in the wheelchair. Resident #1 then pushed their food tray off the table and pushed the table away. The video ended at 4 minutes and 16 seconds with Licensed Practical Nurse #1 shoving Resident #1 in the still locked wheelchair up against a wall. Updated video showed that Resident #1 was able to move themself away from the wall. A review of the internal investigation summary documented that the following morning, 2/27/2025 at 10:30 AM Certified Nurse Assistant #2 approached the Director of Nursing and stated they witnessed Licensed Practical Nurse #1 kicking a resident's wheelchair during mealtime. This conversation/report prompted the Director of Nursing to review the evening video from dinner time. On 2/27/2025 at 11:45 AM all staff that were in the dining room during the incident, were called to the conference room for their statements and were suspended pending the investigation. On 2/27/2025 at 12:PM the Director of Human Resources from corporate was called to come to the facility and they called local law enforcement at 12:57 PM. During an interview on 3/06/2025 at 11:03 Am Certified Nurse Aide #1 stated they saw that the Licensed Practical Nurse #1 held the resident's forehead and tipped the resident's head back and shoved the medications into Resident #1's mouth and then the resident spit it out. The Certified Nurse Aide was not sure, but thought the nurse pinched the resident's nose also. Certified Nurse Aide #1 stated I don't think that was the right thing to do. They stated after the resident spit on them they left the room to clean up. Later in a follow up interview at 11:30 AM they reviewed the video surveillance and stated, they saw that they never left the room. They did not report the abuse to the other Licensed Practical Nurse #2 because one of their coworkers told them that they told the other nurse. Certified Nurse Aide #1 stated that they should have stopped the nurse. During a telephone interview on 3/06/2025 at 12:40 PM Certified Nurse Aide # 2 (in the video they are wearing a blue scrub top), stated they witnessed that Licensed Practical nurse #1 was very upset, and they saw the Licensed Practical Nurse #1 kick the wheelchair a couple of times. They stated that they reported this to License Practical Nurse # 2. During an interview on 3/06/2025 at 1:00 PM Licensed Practical Nurse #2 stated that on the day of the incident Certified Nurse Aide #2 only reported that Licensed Practical Nurse #1 kicked the front little wheel of the resident's chair. Attempted to reach Licensed Practical Nurse #1 on 3/06/2025 at 2:22 PM without success. ----------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified on 02/26/2025 . The facility was back in compliance as of 02/27/ 2025. Once the administration was notified of the situation on the following morning of 2/27/2025 at 11:50 AM multiple corrective actions occurred and are ongoing: After administration viewed the video, a full investigation was started, and at 12:20 PM staff that were on the unit during the incident were brought to the conference room. The three (3) accused staff were suspended, accused Licensed Practical Nurse #1 terminated on 2/28/2025 and information sent to the NYS Education Department and Office of Professionals, and their name is with local authorities with a case open and an open order of protection. The Abuse care plan was updated on 2/28/2025, it documented that on 02/28/2025 the interdisciplinary team discussed the allegation of abuse with the resident. Attending Physician performed an assessment with no negative findings, no changes in resident demeanor were noted. The resident was placed on 1:1 monitoring. Resident #1 was started on 1:1 monitoring on 2/27/2025 at 4:00 PM and remains on 1:1 monitoring for safety and to ensure they have no effects from the incident. The Director of Nursing called the family of Resident #1 at 2:30 PM on 2/27/2025 and after that conversation, the family then spoke with local police and an order of protection was put on file. All other residents were evaluated and assessed on 2/27/2025 between 12:00 PM and 1:00 PM. Social workers began interviewing the residents on 2/27/2025 to ensure they felt safe, and were instructed on how to report abuse or any concerns they might have. They were given the phone number for the Department of Health as well as the Ombudsman. On 3/4/2025 at 3:00 PM met with the Resident Council to ensure all residents are aware of how to report abuse. Interview with Resident Council president on 3/07/2025 at 11:45 AM confirms that they were all spoken with about Abuse and how to report it and they were also given business cards with phone numbers. All other staff have been educated on the importance of informing /reporting immediately and protecting the residents in their care. After incident in-service starting on 2/27/2025 at 2:00 PM with the last one on 3/5/2025 at 4:20 PM with a final complete 100% attendance. On 3/6/2025 at 3:06 PM in an interview with the Director of Human Resources they stated th | 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. |