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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY 811), the facility did not ensure residents rights to be free from abuse for 1 (Resident #7) of 8 residents reviewed for abuse. Specifically, on 3/21/2024 Resident #7 alleged that Certified Nursing Assistant #4 threw towels at them when asking for assistance and yelled at them to say please the next time. Certified Nursing Assistant #4 walked out on the resident without completing care. The facility removed Certified Nursing Assistant #4 from caring for Resident #7, but Certified Nursing Assistant #4 continued to care for other residents for the rest of their shift. Licensed Practical Nurse did not report the incident to their supervisor. The facility investigation concluded abuse occurred as Certified Nursing Assistant #4 would not confirm or deny the allegation. The findings are: The Facility policy Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting of these or other crimes again a resident/client in our care facility revised 11/2022 documented each resident has the right to be free from abuse , neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from coporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. All employees/contract personnel/volunteers must report incident or suspicion of resident/client abuse, neglect, mistreatment, or misappropriation of property to departmental supervisor for further investigation. Resident # 7 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately cognitively impaired. Review of the Facility Investigation Summary dated 03/27/2024 documented Resident #7 alleged that on the morning of 3/21/2024 they asked Certified Nursing Assistant #4 for a towel when they were vomiting, and Certified Nursing Assistant #4 threw the towel at them. In conclusion, Certified Nursing Assistant #4 was suspended and not allowed to return to work due to communication issues during the investigation. All staff were in serviced on abuse prevention and reporting. During an Interview on 1/2/2025 at 1:39 PM, the Social Worker stated they were contacted on 03/21/2024 by Resident #7's family representative via phone. Resident #7's family representative stated Resident #7 reported an incident with an aide the night before to them. The Social Worker stated they went to interview Resident #7 who told them they were vomiting in the early morning hours of 3/21/2024 and hovering over the toilet and they asked Certified Nursing Assistant #4 for a towel. Certified Nursing Assistant #4 brought the towel and threw multiple towels at them and yelled in their face and said, you say please to me. Resident #7 reported that Licensed Practical Nurse #3 intervened and directed Certified Nursing Assistant #4 out of the room. Resident #1 reported that Certified Nursing Assistant #4 did not return to their room after incident. The Social Worker stated they spoke with Licensed Practical Nurse #1 who confirmed they were aware of the incident. The Social Worker stated they followed up by reporting the issue to the Director of Nursing and Assistant Director of Nursing. During an Interview on 1/2/2025 at 12:38 PM, Licensed Practical Nurse #3 stated on the morning of 3/21/2024 that Resident #7 rang their call bell asking for help to change their clothes. Licensed Practical Nurse #3 stated Certified Nursing Assistant #4 went to assist the resident, and about five minutes later Resident #7 rang their call bell again. Licensed Practical Nurse #3 stated when they answered, Resident #7 stated they did not like Certified Nursing Assistant #4 because they were rude, and Resident #7 alleged Certified Nursing Assistant #4 threw a towel at them. Licensed Practical Nurse #3 stated they went into Resident #7's room and finished up assisting the resident and assured them that Certified Nursing Assistant #4 would not be caring for them anymore. Licensed Practical Nurse #3 stated they could not recall if they notified the supervisor about the incident or not. Licensed Practical Nurse #3 stated Certified Nursing Assistant #4 finished their shift on 3/21/2024 but did not care for Resident #7. During an interview on 1/2/2025 at 12:21 PM, Certified Nursing Assistant #4 stated Licensed Practical Nurse #3 asked them to go and assist Resident #7 because the resident was vomiting. Certified Nursing Assistant #4 stated when they entered the room Resident #7 was sitting on the toilet and asked them for a towel. Certified Nursing Assistant #4 stated they could not remember what happened after that and refused to answer the question if they threw the towel at the resident. Certified Nursing Assistant #4 stated continuously that Resident #7 was lying, that the resident was cursing and calling out racial slurs. Certified Nursing Assistant #4 stated Licensed Practical Nurse #3 came into the room and told them not to go back into Resident #7's room. Certified Nursing Assistant #4 confirmed they completed their shift, and they were contacted the next day by Director of Nursing, not to return to the facility due to the incident with Resident #7 and the ongoing investigation. During an Interview on 1/3/2024 at 2:09 PM, the Director of Nursing stated they called Certified Nursing Assistant #4 in for a face-to-face interview and Certified Nursing Assistant #4 would not answer the questions as to whether they threw the towel at Resident #7 or not. The Director of Nursing stated they let Certified Nursing Assistant #4 know they could not return due to their combativeness and unwillingness to answer the questions. The Director of Nursing stated they concluded that Certified Nursing Assistant #4 threw the towel at Resident #7 because Certified Nursing Assistant #4 did not deny the allegation and would not give a direct answer whether they threw a towel at Resident #7 or not. 10 NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedFebruary 11, 2025 F600 What corrective action will be accomplished for those residents affected by the deficient practices? All nursing staff will be in serviced on Resident Rights, Behavior Management, Rough Handling, reportable events and Abuse, Neglect, Mistreatment. This training will be completed by the Nurse Educator/and or her designee .The training will also include the identification of abuse, timely reporting all incidents of abuse to increase abuse prevention. All nurses including RNs, LPNs, RN Supervisors, and other nursing leadership will receive training on Incident Management to ensure that all incidents involving allegations of abuse and intervene to stop suspected abuse immediately.Training will also including informing staff of their responsibility to remove staff involved from duty immediately pending an investigation into the alleged abuse. Ongoing training will also be provided annually and at all new hire orientation to all nursing leadership, RNs,LPNs on Accident, Incident Report and Incident Management to prevent and management incidents of suspected abuse. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents will be evaluated and or screened by the social work team to determine their risk for abuse and a person-centered care plan developed to meet each resident?ÇÖs needs, and prevent unintentional neglect and abuse.Expected date for completion (MONTH) 15,2025. Nurse Manager/and or designee will round and identify any potential residents at risk for abuse; additionally any complaints received by Social Work department will be referred to DON/ADON on call for review and timely reporting of all incidents. Training will also provided to the Social Work department on the Abuse, Neglect, Mistreatment Policy and the Accident, Incident Reporting Policy. This training will be provided by the DON and/or designee. Expected date for completion (MONTH) 27,2025. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The DON created a monthly on call list for timely reporting of all incidents that required reporting on all shifts. The coverage will be provided by the DON/ADONs and each on-call designee is responsible for timely reporting all reportable incidents. The DON/ADONs on call will advise and ensure that the nursing supervisor removes the staff whose care is being investigated from duty. All incidents will be reviewed daily at the nursing leadership morning huddle to ensure all evaluate and assess that the steps for abuse prevention and reporting has been followed. Nurse Managers and off ?Çôtour Nursing supervisors will received training on incident including a pre and posttest for improving competency. All supervisors/nurse manager will round at least two to three times per shift to ensure residents remain safe during the shift during their and report all abuse ?Çôrelated changes and completed a supervisory checklist provided. Any concerns on the checklist will addressed and reported. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e. what quality assurance program will be put into practice The DON or her designee will complete quality audits of all incidents to ensure that the process for early identification, investigation of all allegations of abuse is followed. The audit will be completed daily for four weeks, then weekly for one month, and then monthly for three months. Completion date for audit review (MONTH) 27th 2024. The results from the audit findings will be presented to the QAPI Committee for review on a monthly basis. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY 811 and NY 082), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 2 of 7 residents (Resident #1 and #7) reviewed for abuse and mistreatment. Specifically, on 09/27/23 Certified Nurse Aide #2 reported to Licensed Practical Nurse #1 that Resident #1 was noted with a skin injury to the right side of their head. Licensed Practical Nurse #1 did not check for the injury and failed to notify their supervisor. The facility did not report the incident to the New York State Department of Health until 09/29/23 at 10:36 AM; 2) Resident #7 reported an alleged abuse by that Certified Nurse Aide #4 to Licensed Practical Nurse #3 on 03/21/24. Licensed Practical Nurse #3 did not immediately report the alleged abuse to their supervisor and allowed Certified Nurse Aide #4 to complete their shift interacting and caring for other residents after the alleged abuse incident occurred. The facility did not report the incident to the New York State Department of Health until 03/22/24. Findings include: The facility policy Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting of these or other crimes again a resident/client in our care facility revised 11/2022 documented (1) Each resident/client has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. (2) Supervisor removes staff whose care is being investigated from duty immediately pending results of investigation. 1. Resident # 1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/24 documented Resident #1 was severely cognitively impaired and rarely/never understood. The Incident Progress Note Late Entry by Licensed Practical Nurse #1 dated 09/27/23 documented Resident #1 had a superficial discoloration to the right side of their head during the evening shower, it did not look bad at all to the point of calling the physician at the time. The Incident Report dated 09/28/23 written by the Assistant Director of Nursing documented Resident #1 was encountered lying in bed on their right-side alert with 4cm by 5cm ecchymosis noted to the right eye. Certified Nurse Aide#1 reported Resident #1 was found with bruising during rounding. Physician, Director of Nursing, and Administrator notified. Resident #1 showed no signs of pain and was unable to give a description of what happened. Review of Nursing Home Facility Incident Report submission confirmation sheet dated 09/29/23 documented the report was submitted on 09/29/23 at 10:36 AM. Review of the facility investigation summary dated 10/04/23 revealed Certified Nurse Aide #2 reported that Resident #1 had a skin concern to Licensed Practical Nurse #1 on 09/27/23 and Licensed Practical Nurse #1 failed to write an incident report or notify their supervisor. Licensed Practical Nurse #1 was counseled regarding timely notification for all occurrences to supervisor on duty. During an interview on 12/11/24 at 2:38 PM, Licensed Practical Nurse #1 stated if a Certified Nurse Aide reported an injury of unknown injury, they would go and check the resident and assess and then they will notify the supervisor. Licensed Practical Nurse #1 stated they did not recall the date a Certified Nurse Aide reported Resident #1 had a skin issue. Licensed Practical Nurse #1 stated they went to assess Resident 1 after the staff informed them of Resident #1 but the mark on the skin did not look like anything of concern, and they thought it would go away. Licensed Practical Nurse #1 stated they were written up for not reporting immediately. Licensed Practical Nurse #1 stated they had planned to report the injury to their supervisor before their shift ended but they forgot. Licensed Practical Nurse #1 stated they were re-in serviced on abuse/neglect and timely reporting of incidents to supervisor prior to returning to work. During an interview on 12/11/24 at 1:08 PM, the Director of Nursing, stated they were notified during morning meeting on 09/29/24 that Resident #1 had some swelling. The Director of Nursing stated they initiated the investigation immediately and could not substantiate the complaint. The Director of Nursing stated the expectation is for staff to notify them regarding incidents or accidents at any time. The Director of Nursing stated even if they were unavailable, they have a schedule that indicate who else to notify in their absence and the schedule is available to staff. 2. Resident # 7 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/24 documented a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately cognitively impaired. Review of Facility Investigation Summary dated 03/27/24 documented Resident #7 alleged that on the morning of 3/21/24 they asked Certified Nurse Aide #4 for a towel when they were vomiting, and Certified Nurse Aide #4 threw the towel at them. Certified Nurse Aide #4 was suspended and not allowed to return to work due to communication issues during the investigation. All staff were in serviced on abuse prevention and reporting. Review of facility submission confirmation sheet dated 03/22/24 documented Nursing Home Facility Incident Report was submitted on 03/22/24 at 11:10 AM. During an interview on 1/2/25 at 1:39 PM, the Social Worker stated they were contacted on 03/21/24 by Resident #7's daughter via phone. Social Worker stated Resident #7's daughter alleged Resident #7 reported an incident with an aide the night before between midnight and 2:00 AM. Social Worker stated interviewed Resident #7 who stated they were vomiting in the early morning hours of 3/21/24 and hovering over the toilet. Resident #7 reported to the Social Worker that they asked Certified Nurse Aide #4 for a towel and Certified Nurse Aide #4 threw multiple towels at them and yelled in their face you say please to me. Resident #7 reported to Social Worker that Licensed Practical Nurse #3 intervened and directed Certified Nurse Aide #4 out of the room. Resident #1 reported to Social Worker the aide never returned to their room after the incident. Social Worker stated they spoke with Licensed Practical Nurse #1 who stated they were aware of the incident. Social Worker stated they followed up by reporting the issue to the Director of Nursing and Assistant Director of Nursing. During an Interview on 1/2/25 at 12:38 PM with Licensed Practical Nurse #3, they stated on the morning of 3/21/24, Resident #7 rang their call bell asking for help to change their clothes. Licensed Practical Nurse #3 stated Certified Nurse Aide #4 went to assist the resident, and about five minutes later Resident #7 rang their call bell again. Licensed Practical Nurse #3 stated when they answered, Resident #7 stated they did not like Certified Nurse Assistant #4, because they were rude, and Resident #7 alleged Certified Nurse Assistant #4 threw a towel at them. Licensed Practical Nurse #3 stated they went into Resident #7's room and finished up assisting the resident and assured them that Certified Nurse Assistant #4 would not be caring for them anymore. Licensed Practical Nurse #3 stated they could not recall if they notified the supervisor about the incident or not. Licensed Practical Nurse #3 stated Certified Nurse Assistant #4 finished their shift on 3/21/24 but did not care for Resident #7. During an Interview on 1/2/25 at 12:21 PM with Certified Nurse Assistant #4, Certified Nurse Assistant #4 stated Licensed Practical Nurse #3, asked them to go and assist Resident #7 because the resident was vomiting. Certified Nurse Assistant #4 stated when they entered the room Resident #7 was sitting on the toilet and asked them for a towel. Certified Nurse Assistant #4 stated they could not remember what happened after that and refused to answer the question if they threw the towel at the resident. Certified Nurse Assistant #4 stated continuously that Resident #7 was lying, that the resident was cursing and calling out racial slurs. Certified Nurse Assistant #4 stated Licensed Practical Nurse #3 came into the room and told them not to go back into Resident #7's room. Certified Nurse Assistant #4 confirmed they completed her shift, and they were contacted the next day by Director of Nursing, not to return to the facility due to the incident with Resident #7 and the ongoing investigation. During an interview on 1/3/24 at 2:09 PM, the Director of Nursing stated their expectation is that staff report any abuse or neglect allegations to their supervisor for the supervisor to follow up. The Director of Nursing confirmed they were not made aware of abuse allegation regarding Resident #7 until 03/22/23 by the Social Worker. The Director of Nursing confirmed Licensed Practical Nurse #3 did not report allegation of abuse until being interviewed regarding the allegation on the morning of 3/21/23. The Director of Nursing stated at night they would not expect the staff member to be suspended but would expect for them to reassign the resident to another aide or remove staff from doing patient care. The Director of Nursing stated they could not say for sure if the Certified Nurse Aide #4 provided care for the remainder of their shift on 3/21/24 but their policy is that staff must be removed from the unit pending investigation. 10NYCRR: 415.4(b) | Plan of Correction: ApprovedFebruary 7, 2025 F609 What corrective action will be accomplished for those residents affected by the deficient practices? For residents affected by the deficient practice all staff involved in allegation of abuse will be removed from duty as per policy pending an investigation.To prevent the deficient practice all nursing staff will receive training and education on reportable incidents and Patient Incident Management. Training and education will also be provided to the nursing leadership on reportable incidents and and following the steps for ensuring the safety of all residents when there is an allegation of abuse i.e. removing the accused staff from interacting and caring for other residents. Date of completion for training (MONTH) 28, 2025. Training will also be provided on an annual basis and to all new hires. Training will be coordinated by the Nurse Educator and or her designee. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken To prevent the deficient practice nurse manager and or nurse supervisors will conduct periodic rounding at least two to three times per shift and observe for incidents that need further investigation,and or reporting. All incidents reports will be reviewed and just in time training provided when fall outs or non-compliance are observed. During rounding nursing supervision will prioritize any reports of incidents that require immediate reporting What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The following policies will be reviewed with all nursing staff including nursing supervision, Abuse,Mistreatment,Neglect and Incident Accident Reporting. Policy review will be coordinated by the Nurse Educator and or designee. Expected date of Completion (MONTH) 15,2025. How the corrective actions will be monitored to ensure the deficient practice will not recur i.e. what quality assurance program will be put into practice The DON or her designee will complete quality audits of all incidents to ensure that the process for early identification, reporting investigation of all allegations of abuse was followed. The audit will be completed daily for four weeks, then weekly for one month, and then monthly for three months. Completion date for audit review (MONTH) 27th 2024. The results from the audit findings will be presented to the QAPI Committee for review on a monthly basis. |