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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during an abbreviated survey (Case #NY 658), the facility did not ensure it protected the resident's right to be free from abuse and neglect for 1 (Resident #1) of 3 residents reviewed. Specifically, Registered Nurse #1 forcefully removed Resident #1 from the floor after the resident became unsteady and fell to the floor. Registered Nurse #1 did not assess the resident for injury prior to getting the resident up and ambulating them to their room. This is evidenced by: The Facility's Abuse Policy Prevention program updated on 10/20/2024 documented the following: Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 09/11/2024, documented Resident #1 could sometimes be understood and sometimes understand others with severely impaired cognition for daily decision making. The facility's abuse investigation dated 10/17/2024 through 10/18/2024, documented that Video footage identified that Registered Nurse #1 approached Resident #1 on 10/17/2024 at 11:19 PM at the nurse's station as Resident #1 was urinating on the floor. Registered Nurse #1 attempted to turn Resident #1 and direct them to their room. Resident #1 lost their balance and fell to the floor. Registered Nurse #1 picked the resident up off the floor by their left arm and then led Resident #1 down the hallway towards their room. Resident #1's pants were about a quarter way down their rear end as they walked, swaying back and forth. The record indicated that Certified Nurse Aide #1 heard a commotion on 10/17/2024 at approximately 11:15 PM and saw Registered Nurse #1 ushering the resident down the hallway. Resident #1 was on the floor, Registered Nurse #1 told Certified Nurse Aide #1 to leave the resident on the floor to calm down. Registered Nurse #1 was using foul language and was angry so Certified Nurse Aide #1, waited until they could safely leave the unit, then they went and notified Licensed Nurse #1, on the other unit of the suspected abuse. Licensed Practical Nurse #1 called The Registered Nurse Supervisor on call and notified them of the suspected abuse. Licensed Practical Nurse #1 was told to tell Registered Nurse #1 to leave the building Registered Nurse #1 turned in their medication keys and left the building. Registered Nurse #2 and the Administrator #1 arrived at the facility by 1:30 AM. Resident #1 was assessed; the physician was notified, and the significant other was called. Police responded to the call and arrived at the building at 3:15 AM on 10/18/2024 and took the report of the suspected abuse. The family declined pressing charges. The on-call physician was notified at 2:15 AM. X-rays were done, and no physical harm was identified. Staff monitored Resident #1, and no psychosocial harm was observed. New York State Department of Health was notified per regulation. The investigation was started and review of the cameras on the unit was done which provided evidence that substantiated and corroborated the report from Certified Nurse Aide #1. The facility determined abuse had occurred, and Registered Nurse #1 was suspended and later terminated. Re-education on abuse/neglect and reporting of suspected abuse regardless of who is suspected was completed with all facility staff A facility video that began on (time stamp of) 10/17/2024 at 11:15 PM, was reviewed and documented the following: - Resident #1 was by the nurse's station on their unit. - Registered Nurse #1 was seated at the nurses' station, across from Resident #1. They did not engage with the resident. No other staff was seen in video view. -Resident #1 stood with their back to grabbed the resident from behind and placing their hands on the residents' shoulders. - Resident #1 appeared startled and became unsteady, fell to the floor on their right side, and their left arm to shoot up in the air. Registered Nurse #1 grabbed Resident #1's left arm with both hands and pulled the resident to their feet and directed them to their room. - Noted that no assessment was done by Registered Nurse #1 prior to pulling Resident #1 to their feet. A physician progress notes [REDACTED].#1 had an incident with staff on 10/18/2024 where they were urinating on the floor at the nurse's station. Staff member was forcefully escorting resident back to their room and the resident fell on to the floor, landing on their right side. Resident #1 was then forcefully pulled up from the floor by their left arm and hurried down the hall back to their room. They then apparently fell again in the doorway. Imaging done shows no acute injury. A physician progress notes [REDACTED].#1 had an incident with staff on 10/18/2024 where they urinated on the floor at the nurses' station. Staff member was seen forcefully escorting resident back to their room and resident fell on to the floor, landing on their right side. Resident was then forcefully pulled up from the floor by their left arm and hurried down the hall back to his room. Resident #1 had [MEDICAL CONDITION] and did not recall the incident. Resident denied any chest pain, dizziness, sob, cough, pain, or discomfort. During an interview on 10/21/2024 at 10:45 AM, Administrator #1 stated they had been notified by the on call Registered Nurse Supervisor of the incident and went to the facility. When they arrived at approximately 1:30 AM on 10/18/2024, Resident #1 was assessed for injuries; Administrator #1 watched video from cameras on the unit; Abuse was identified after watching the video, the on-call physician was notified, and orders for x-rays were obtained to assess for any fractures (bone breaks) after seeing how the resident was yanked off the floor by Registered Nurse #1. Administrator #1 further stated they notified Resident #1's Health Care Proxy and police; Police Officers arrived on 10/18/2024 at 3:15 AM and took a report. Administrator stated: Resident #1's Health Care Proxy declined to press charges; Staff and Physician continued to monitor Resident #1 for physical and psychosocial harm; All staff received education on reporting abuse; Registered Nurse #1 was reported to the (New York State Department of Education State Board of Nursing) by the facility for abuse. Administrator #1 stated there was no doubt that abuse occurred after the video was watched, and that Registered Nurse #1 had not assessed the resident after the fall. Administrator #1 stated they should have called the doctor and waited for someone to assist them before getting the resident up off the floor. During a phone interview on 10/22/2024 at 9:35 AM, Certified Nurse Aide #1 stated they thought Registered Nurse #1 'was acting funny,' witnessed Registered Nurse #1 pull the resident up off the floor, but did see them, rushing Resident #1 to their room. Certified Nurse Aide #1 stated Nurse Supervisor was notified that abuse of a resident was suspected, and Registered Nurse #1 was asked to leave the building. During an interview on 10/22/2024 at 10:35 AM, Registered Nurse #1 stated during the night shift, Resident #1 was urinating on the floor by the nurse's station; they attempted to stop the resident and turned them around to take them back to their room. Resident #1 became unsteady and 'went to the floor.' Registered Nurse #1 stated that in the attempt to lower the resident to the floor, Registered Nurse #1 grabbed the resident by the arm and tried to lower them, then picked the resident up off the floor and walked them to their room. Registered Nurse #1 stated they should have gotten someone to help them and should have followed policy and procedure to prevent injury to the resident. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey. 1. Developed and implemented education to address concerns with reporting allegations of abuse no matter who the accuser was. 2. Posters were placed in areas with expectations that demonstrated reporting for any allegations of abuse. 3. Power Point and reeducation to all facility staff with 100 percent compliance on abuse and neglect and reporting 4. Registered Nurse #1 was removed from resident care immediately and terminated from the facility after the investigation was completed within 5 days of the incident. 5. Resident #1 Comprehensive Care Plan for Victim of Abuse was implemented, and Behaviors Care Plan was updated. 6. Family/Physician/and Police notification was completed within 2 hours of the incident on 10/17/2024 7. Reporting to New York State Department of Health was completed within 2 hours of the incident on 10/17/2024 8. An investigation was started (MONTH) 18, 2024, at 1:30 AM, and was completed on (MONTH) 22, 2024, by 5:30 PM and presented to the surveyor. 9. Resident #1 was assessed on 10/18/2024 for injury and orders for x-rays completed to further assess. No injuries found. 10. Audits on going to ensure staff knowledge and response education has been sufficient. Every week for 4 weeks and monthly for 4 months. 10 New York Codes, Rules, and Regulations 415.4(b)(1)(i) | Plan of Correction: ApprovedFebruary 13, 2025 A plan of correction is not required for past non-compliance deficiencies. The facility remains responsible via continued implementation of the corrective actions developed by the facility to ensure ongoing compliance. |