NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 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 342) the facility did not ensure that one of three residents (Resident #1) was free from abuse. Specifically, Certified Nurse Assistant #1 with Registered Nurse #1 were in the shower room giving Resident #1 a shower in a shower bed. Resident #1 kicked towards Certified Nurse Assistant #1 and Certified Nurse Assistant #1 smacked Resident #1's upper right leg with an open hand to push Resident #1's leg away from their body. Registered Nurse #1 was startled by the action and immediately called the supervisor to report what had happened. The Findings are: The Facility policy last reviewed 6/24 titled Abuse Prohibition- Freedom from Abuse, Neglect, Exploitation documents that it is the policy of the facility to protect residents from abuse, neglect, mistreatment, exploitation or misappropriation of property in accordance with state and federal regulations. Resident #1 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] indicated that Resident #1 is severely impaired to make decisions regarding tasks of daily living. Nurse Initial Shift note effective date 1/20/25 at 12:29pm, documents Resident #1's status prior to incident. Documents general: received in the wheelchair, appears comfortable, weights and vitals stable. Cardiovascular: cardiac rate/rhythm within normal limits, capillary refill less than 3 seconds. Skin is intact, warm, no presence of [MEDICAL CONDITION], peripheral pulse palpable, and strong blood pressure within normal limits. The rest of assessment/note indicates all was within normal limits. Skin assessment in this same note documents skin is intact, normal pigmentation consistent with residents' baseline, [DIAGNOSES REDACTED] on [DEVICE] site, barrier ointment applied as ordered, bony prominences protected. Physician Interim note effective date 1/20/25 at 5:14pm documents that Resident #1 was assessed related to incident. Awake alert acting as normal and in good mood. Skin in general no redness or [MEDICAL CONDITION]. Head and face with scalp and skin intact no swelling or color changes. Abdomen no skin color change, no distension out of his baseline, soft nontender no guarding, [DEVICE] in place. Extremities with no swelling or color changes. No signs of pain with gentle passive range of motion in all extremities. Right upper thigh area with skin intact no color changes no swelling no tenderness. No trauma or injury noted related to the incident. Follow up as needed. Resident #1 has a care plan-initiated date of 5/11/23 with a focus that reads - the resident has risk factors leaving them vulnerable to potential/actual mistreatment. The goal is that resident will remain safe from any psychological/physical/emotional/verbal abuse and or maltreatment by/though next review date. Interventions listed are: - identify any signs of potential abuse (injuries, poor hygiene, symptoms of anxiety, depression, confusion). - provide resident with safe and meaningful activities. The facility's incident report and the witness statement from the facility's internal investigation documented that on 1/19/25 Registered Nurse #1 was with Certified Nurse Assistant #1 in the shower room giving Resident #1 a shower in the shower bed. The Certified Nurse Assistant #1 was standing on the left side of Resident # 1. The resident kicked towards Certified Nurse Assistant #1, and they smacked Resident #1's upper right leg with an open hand to push it down away from themselves. It was a sudden reflexive response. Registered Nurse #1 was startled by the action and immediately called the supervisor to report what had happened. Immediately after the incident the Certified Nurse Assistant #1 was removed from the unit and brought to the lobby. The Director of Nursing was called and notified, Resident #1 was examined, there was no mark or redness, a head-to-toe assessment was completed and showed no unusual bruising, swelling or other sings of injury. The Certified Nurse Assistant #1 was suspended and later terminated. On 1/27/25 at 12:19pm in an interview with Certified Nurse Assistant #2, who frequently provides care for Resident #1, they stated that Resident #1 flails and kicks out often, but what they do to ensure safety is always keep eyes on resident and back up to prevent them from hitting you. Certified Nurse Assistant #2 stated that Resident #1 flails at times, we try to explain what we are doing, and they understand, and they stay more relaxed. Certified Nurse Assistant #2 stated that when Resident #1 kicks, I try to stand back, and when they are tired, they kick more it seems. Certified Nurse Assistant #2 stated that when you explain to them what you are doing, they understand and often are better with cares. On 1/28/25 at 9:15am in a phone interview with Certified Nurse Assistant #1 they stated that they were showering Resident #1, and they were acting up and kicking out as per their usual and their feet were coming near them, it was a reflective action, when something is coming at you; you move it away with no intention to harm. Certified Nurse Assistant #1 stated that normally when they kick, I don't do anything, but on that day, it was just a reflex. Certified Nurse Assistant #1 stated that Resident #1 was not usually on their assignment; they were short staffed, the person that is usually there had called out. Certified Nurse Assistant #1 stated that 1 or 2 times a week they have call outs, the facility tries to find staff to cover, but sometimes they must cover. Certified Nurse Assistant #1 states that evening the weather was bad and there were more call outs than usual. Certified Nurse Assistant #1 stated that Resident #1 acts up all the time. Certified Nurse Assistant #1 was not aware that there could be a 3rd person assist, they had never seen that occur. Certified Nurse Assistant #1 stated they would need to have 2 Certified Nurse Assistants and a Nurse, and there are not 2 Certified Nurse Assistants available to help with cares. Certified Nurse Assistant #1 recalls a presentation on abuse, but it was not something they emphasized. Certified Nurse Assistant #1 stated that at the time they were not sure how to handle the situation. Certified Nurse Assistant #1 stated they love the kids and would never do anything to harm them. Certified Nurse Assistant #1 stated that they had never been given specific instructions on how to take care of Resident # 1. On 1/28/24 at 11:32am in an interview with Director of Nursing, they stated that they oversee all resident care and all investigations for abuse, neglect, and mistreatment. Director of Nursing stated that in their [AGE] years working at the facility they recall only 2 abuse cases. Director of Nursing stated that they think that Certified Nurse Assistant #1 responded in a reflexive way to protect themselves from possibly being kicked. Director of Nursing stated they do not think it was done with any malintent and maybe it was just a reflex/instinctive reaction. Director of Nursing stated that Certified Nurse Assistant #1 started working at the facility this past (MONTH) and they received training at that time. 10NYCRR 415. 4(b) | Plan of Correction: ApprovedMarch 19, 2025 1)CNA #1 was immediately removed from unit, interviewed and investigative statements obtained, followed by immediate suspension pending completion of investigation. Resident was promptly assessed by the Nurse supervisor and noted to have no redness or marks to his body including upper right leg. No sign of discomfort, upset or change from baseline status was seen. A comprehensive investigation was initiated that included review of policy and procedure, interview of staff, review of surveillance footage and medical record. It was confirmed that CNA #1 had participated in multiple trainings on Abuse since date of hire 8/5/ 24. CNA #1 was initially trained in the abuse prohibition policy on date of hire 8/5/2024 as well as Care of Cognitively Impaired Residents on 8/12/2024 as well as Response to Abuse of Residents on 8/24/ 2024. In addition, CNA #1 completed follow up training on Abuse, Neglect and Mistreatment on 9/20/ 2024. Since that time, she received and reviewed monthly Newsletters that contained ongoing education on various aspects of the Abuse Prohibition Policy. On investigation, CNA #1 was tearful and remorseful. She indicated over and over ?ôI would never hurt him, I thought I was going to be kicked and I just reflexively reached out to prevent it.?Ø Resident is noted to have unpredictable non purposeful movements especially during bathing. His plan of care was updated to include strategies during shower and ADL care as well as behavioral strategies to address these movements and to support the resident during ADL care. CNA #1 was terminated upon completion of investigation. Residents parents were notified; investigative findings as well as corrective actions were reviewed. The parents were satisfied and appreciative of the update. 2)To protect residents at risk, the facility will continue to monitor, through daily morning report review, behavior health rounds, care plan meetings, occurrence report reviews, for any changes in condition, changes in behavior, or injuries of unknown origin. All identified changes will be subject to the investigative process. In addition, quarterly Psychosocial assessments have been updated to include enhanced list of risk factors and interventions that will guide comprehensive care planning, referrals to Behavioral Health team and indicated staff training. An initial review of all 122 residents was conducted by the interdisciplinary team which identified a total of 8 residents with similar behaviors during care. ADL care plans were updated with new interventions and behavioral care plans updated and in 4 cases, initiated. 3)To reduce the risk of further occurrences, all staff including but not limited to direct care staff and ancillary staff will be re-in serviced, Education will focus on all aspects of the Abuse Prohibition Policy as well as managing residents with aggressive/active and non-purposeful movements. Education will include didactic presentations, online learning exercises, competency-based training, staff meetings, and/or monthly newsletters. 4)The Director of Nursing will monitor ongoing compliance rates of all departments to the successful completion of quarterly educational efforts related to abuse prevention. Compliance rates will be monitored using an audit tool that will calculate compliance rates for quarterly training. The Director of Nursing will conduct the audits and report in writing, at least quarterly, to the Administrator and Quality Committee, the findings and any corrective actions for a period of not less than 18 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 1/21/2025 by the Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews completed during an abbreviated survey (NY 157 & NY 502), the facility did not ensure that 2 different residents received treatment and care in accordance with their comprehensive person-centered care plan. Specifically Resident #2 and Resident # 3 had care plans in place, that documented that they required 2 staff members to provide all care. In each identified instance a single Certified Nurse Assistant provided care singlehandedly to each resident. The Finding is: The Facility policy titled Safe Resident Handling that was in effect at the time of the incidents has been effective since 2/1995 and updated and revised multiple times most recently after the 2 incidents with Certified Nurse Assistants providing care alone. The Policy Safe Patient Handling dated 10/2023 documents that the number of staff assistance needed for care is indicated in the care plan/Kardex. The updated policy dated 1/2025, after the two incidents documents: Additionally, all residents that are greater than 35lbs and dependent for Activity of Daily Living performance will be a 2-person assist for Activity of Daily Living care including showering, dressing, diaper changes and positioning, unless otherwise care planned, and this will be indicated with a I take two symbol at residents' bedside and indicated in the care plan/Kardex. Resident #2 originally admitted on [DATE] with [DIAGNOSES REDACTED]. fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D). Resident #2 Minimum data set, a resident assessment and screening tool, dated 8/9/2024 indicate that the 8-year-old resident was completely dependent on others for all activities of daily living, Resident #2 is not capable of letting their needs be known. The investigative summary documents that the event occurred on 10/11/2024, at 1:15pm Resident #2 was receiving Occupational Therapy services, and it was noted that there were irregular movements at the left distal femur. Resident #2 had some redness, and they grimaced with manipulation. Therapy was stopped, Registered Nurse #3 was notified, Nurse Practitioner notified, and Nurse Manager. Portable X-Ray ordered, result indicated left mid diaphysis femur fracture (a broken bone in the middle shaft - diaphysis - of the left femur - thigh bone) and Resident #2 was sent to the hospital. Per the facility internal investigation prior to this fracture, Resident #2 had been resting in bed, and was changed 1 time at 5:04am by a single Certified Nurse Assistant (Certified Nurse Assistant #6). Certified Nurse Assistant #6 did not return a call from Department of Health. Certified Nurse Assistant #6's statement in the investigative report is that they changed Resident #2 without assistance because they thought that Resident #2 was only a 2 person assist for transfer and shower and did not realize it was also for diaper changes. Resident #2 is care planned and it is on their Kardex that they are a 2 person assist for all activities of daily living, however, the Certified Nurse Assistant #6 did not check the Kardex prior to providing care. Resident #3 originally admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3's Minimum data set, a resident assessment and screening tool, dated 5/31/2024 indicated that the [AGE] year-old resident was severely cognitively impaired and is completely dependent on others for all activities of daily living, Resident #3 is not capable of letting their needs be known. Reviewing the internal facility investigation summary on 6/16/2024 Certified Nurse Assistant #7 changed Resident #3's diaper without assistance, even though the care plan and Kardex for Resident #3 states 2 person assist. The statement from Certified Nurse Assistant #7 is that they changed Resident #3 alone because the nurse was very busy with a different resident most of the night. The Certified Nurse Assistant #7's statement is that they saw Resident #3's leg and it did not look unusual, red, or swollen ever throughout the night during the times they were in to change Resident #3's diaper. Resident #3 had a straight catheterization at 7am with 2 staff present, Certified Nurse Assistant #6 and Registered Nurse # 5. At this time the leg did not have any change in appearance, it was not until 8:30am when the same two staff went in to change Resident #3's diaper that the leg was noticed to be swollen, and there was a noticeable change in the alignment of Resident #3's leg. Protocol was followed and Resident #3 had a stat bed side Xray done and the result indicated a right comminuted mid shaft femur fracture (a comminuted - broken into many pieces - bone in the middle shaft of the right femur - thigh bone) and Resident #3 was transferred to the hospital. Certified Nurse Assistant #7 returned the surveyor's call on 2/7/2025 at 9am and in the interview that followed they stated that they were not aware that the Kardex had changed. Certified Nurse Assistant #7 stated they had often changed the diaper for Resident #3 alone, because they did not check the Kardex. Certified Nurse Assistant #7 stated that when they had gone in to provide cares, Resident #3's leg did not look different in any way. Certified Nurse Assistant #7 stated that since the incident this no longer occurs because there are signs, and the facility changed the assignment process and the assignment sheet; now staff work as a team with every resident. In an interview on 2/6/2025 at 9am with Registered Nurse #5 they stated that they, along with Certified Nurse Assistant #6 had gone in early in the morning to straight catheterize Resident #3 and there were no issues noted with Resident #3's leg. Registered Nurse #5 stated it was not until much later in the morning at around 8:30am that they noticed that Resident #3 had a misalignment with their leg. Registered Nurse #5 stated they were not aware that the Resident #3 had been provided Activities of Daily Living cares alone during the over night shift. 10NYCRR 415. 12 | Plan of Correction: ApprovedMarch 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1)Immediate actions for investigation regarding resident #2 included resident assessment by Nurse Practitioner, statement collection from indicated staff, review of medical record, review of Central Monitor pulse oximetry-heart rate data and review of video surveillance. Corrective actions included review of all policies and procedures pertaining to safe positioning and handling, ADL care as well as Osteopenia. Re-evaluation of residents care plans by Rehabilitation Services including transfer and ADL care. Comprehensive Plan of Care reviewed and updated on return form ACF and reviewed with caregivers. Review found that resident was identified, and care planned for- at risk for fracture related to immobility and complexity of [DIAGNOSES REDACTED].#6 was suspended from duty pending investigation with subsequent disciplinary action and remediation for non-compliance with 2-person assist. The residents mother was notified and further updated by DNS and Administrator regarding the occurrence, investigative conclusions and updates to plan of care. Immediate corrective actions for investigation regarding resident #3 addressed both non-compliance with 2 person assist, as well as safe positioning for urinary catheterization for contracted residents. Immediate remediation with disciplinary action for CNA # 7. Rounds on all units to confirm placement of picture signage with the emoji (not words) of a hand holding up 2 fingers indicating 2-person assist. This emoji is referred to as ?ôI Take 2. ?Ø Mandatory acknowledgement for Nursing staff in employee portal of ?£Safe Handling Advisory.?Ø Corrective action include-Review of all policies and procedures pertaining to safe positioning and handling as well as Osteopenia. Review and updates to Policy and Procedure for Urinary Catheters with additional requirement of alternate positioning needs for procedure to be specified in the plan of care and require a medical order. Re-evaluation of resident by Rehabilitation Services on return from ACF for review of Plan of Care, including positioning for catheterization, transfer and ADL care. Inservices were conducted with nursing staff on these updates to resident #3 plan of care. Parents were notified and updated by DNS and Administrator, they verbalized understanding of resident [MEDICAL CONDITION] diagnosis, active treatment with infusion therapy already in place and continued risk for fracture. They expressed appreciation for the detailed report including updates to ADL care and catheterization. 2)As a corrective action following investigation for resident #2, the policy and procedure for ADL care was revised. As an added safety intervention, ALL residents greater than 35lbs and fully dependent in ADL performance will be two-person assist for all ADL care that requires moving. Review of all 122 residents indicates that 81 residents require 2-person assist. Revision of CNA assignments on all shifts to identify teams for ADL care to facilitate consistent compliance with 2-person assist. Mandatory training with competency assessment for all Nurses and CNAs to include updates to policy and implementation of team assignments. All residents admitted to Sunshine are care planned on admission for risk for Osteopenia and fracture due to the complex medical diagnoses, decreased mobility and non-ambulatory status. Mandatory review inservice was conducted including competency with all Nursing Staff on Osteopenia and Risk for Fracture and Safe Positioning and Handling. Training included use/navigation of resident Kardex to identify resident needs, working together CNA with CNA or NURSE-CNA to ensure safety. In addition In order to identify others at risk, related to this occurrence for resident #3, a re-evaluation of all Sunshine residents requiring intermittent catheterization was conducted with the Rehab team for need for alternate positioning needs for this procedure. 3)Two-person assist compliance audits were initiated and completed by Nurse Managers and off shift Supervisors. Audits will be continued monthly on all shifts, for a period of 12 months. 4)Monthly audit results and chart reviews will be reported in writing, at least quarterly, to the Administrator and Quality Committee, their findings and corrective actions for a period of not less than 12 months, with ensuing frequency as determined by the Quality Committee. 5)Initiated 10/20/2024 by the Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY 342), the facility, regarding an incident of staff-to-resident suspected abuse, did report the incident immediately, but not later than 2 hours, to the State Agency, but did not report the incident immediately, but not later than 2 hours, to local law enforcement. This was identified for one of 3 residents (Resident #1) reviewed for abuse. Specifically, Certified Nurse Assistant #1 with Registered Nurse #1 were in the shower room giving Resident #1 a shower in a shower bed. Resident #1 kicked towards Certified Nurse Assistant #1 and Certified Nurse Assistant #1 smacked Resident #1's upper right leg with an open hand to push Resident #1's leg away from their body. The facility did not report the suspected abuse to local law enforcement. Findings include: The facility policy titled Abuse Prevention- Freedom from Abuse, Neglect, Exploitation revised 6/24 documents that it is the policy of the facility to protect residents from abuse, neglect, mistreatment, exploitation or misappropriation of property in accordance with state and federal regulations. Furthermore, it documents that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. Resident #1 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] indicated that Resident #1 is severely impaired to make decisions regarding tasks of daily living. Review of the nursing notes indicates that there is no nursing note from Registered Nurse #1 that reported the incident. Physician Interim note effective date 1/20/25 at 5:14pm documents that Resident #1 was assessed related to incident. Awake alert acting as normal and in good mood. Skin in general no redness or [MEDICAL CONDITION]. Head and face with scalp and skin intact no swelling or color changes. Abdomen no skin color change, no distension out of his baseline, soft nontender no guarding, [DEVICE] in place. Extremities with no swelling or color changes. No signs of pain with gentle passive range of motion in all extremities. Right upper thigh area with skin intact no color changes no swelling no tenderness. No trauma or injury noted related to the incident. Follow up as needed. The facility's incident report and the witness statement from the facility's internal investigation documented that on 1/19/25 Registered Nurse #1 was with Certified Nurse Assistant #1 in the shower room giving Resident #1 a shower in the shower bed. The Certified Nurse Assistant #1 was standing on the left side of Resident # 1. The resident kicked towards Certified Nurse Assistant #1, and they smacked Resident #1's upper right leg with an open hand to push it down away from themselves. It was a sudden reflexive response. Registered Nurse #1 was startled by the action and immediately called the supervisor to report what had happened. Immediately after the incident the Certified Nurse Assistant #1 was removed from the unit and brought to the lobby. The Director of Nursing was called and notified, the resident was examined, there was no mark or redness, a head-to-toe assessment was completed and showed no unusual bruising, swelling or other signs of injury. The Certified Nurse Assistant #1 was suspended and later terminated. The Director of Nursing sent in a report to the Department of Health on (MONTH) 20th by 11:07 AM with the identified allegation type listed as Physical Abuse. In an interview with the Director of Nursing on 1/29/25 at 11:30am they stated they did not call the Local Police department regarding the 01/19/25 incident. The Director of Nursing stated that the Attorney General's office communicated with them (called and emailed) on 01/23/ 25. The Director of Nursing stated that they did not call the local Police Department because their interpretation was that it was not a crime, there was no injury at all, not even a mark, and Resident #1 was not in any distress - they are hooked up to monitors that register their vitals and the monitors did not indicate any change from the norm. In an interview on 1/29/25 at 11:45am with the Administrator, it was pointed out that the local authorities were not contacted. The Administrator stated that they did not call the local authorities because they knew that the incident was not a crime or in any way suspicious. The Administrator stated that the Certified Nurse Assistant #1 acted reflexively and had absolutely no willful intent. The Administrator stated it was not in their mind a crime. The Administrator stated they also had interactions with the Attorney General's office, who had contacted them, and that the Attorney General had informed them that it was ok that they had not called in the local authorities. In a subsequent interview with the Director of Nursing on 2/27/25 at 1:20pm they stated that it was an oversight, but there is no nursing note regarding the 11/19/25 staff to resident incident. The Director of Nursing stated that Registered Nurse #1, the nurse that reported the incident, wrote only one note on 1/19/25 at 12:09pm, but that note was not about the staff to resident incident. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedMarch 19, 2025 1)The Director of Nursing spoke with the NYS Attorney Generals Office and reviewed investigative findings and submitted requested information. Policy and Procedure on reporting to local authorities updated 2)The Administrator spoke with the Lieutenant of the New Castle Police Department to review and confirm requirements of notification for any suspected abuse incidents. All resident occurrences were reviewed and confirmed that appropriate action was taken in all cases involving abuse. 3)To reduce risk of reoccurrence, the administrator or designee will immediately report any suspected cases of abuse to the appropriate State agency and law enforcement. Inservice training on abuse reporting requirements will be conducted for all staff at a minimum of no less than quarterly. 4)The Director of Nursing will monitor ongoing compliance by reviewing and signing off on all resident occurrences to ensure compliance with reporting requirements. Compliance rates for reporting of abuse and notification to local law enforcement will be monitored and will be reported in writing, by the Director of Nursing at least quarterly, to the Administrator and Quality Committee, their findings and corrective actions for a period of not less than 18 months, with ensuing frequency as determined by the Quality Committee. 5)Initiated 1/21/2025 by the Director of Nursing |