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: Actual harm has occurred
Citation date: April 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during an abbreviated survey (NY 683), the facility failed to ensure that the resident environment was free of accident hazards and/or that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents reviewed for accidents. Specifically, staff did not implement interventions as per the care plan for Resident #2 who required 2-person assist for bed mobility, transfers and all activities of daily living. There were two (2) separate incidents that occurred with different staff each time. The first incident occurred on [DATE], when Certified Nurse Aide #3 found Resident #2 on the floor in the residents' room and used a Hoyer lift (a mechanical lift device) by themselves to move the resident back into their bed. The second incident occurred on [DATE], when Certified Nurse Aide #4 went into Resident #2's room alone to provide care. The resident sustained [REDACTED]. On [DATE], Resident #2 was transferred to the hospital for evaluation of their injuries. They were diagnosed with [REDACTED]. The Medical Examiner concluded that the resident expired from [MEDICATION NAME] force trauma to the head. This resulted in actual harm to Resident #2 that is not immediate jeopardy. The Findings Include: The [DATE] policy titled Activities of Daily Living Care Plan documented to develop resident activities of daily living care plan upon admission, the purpose is to serve as a guide to caregivers to meet the individual residents' needs and Certified Nurse Aide is responsible for referring to and using the Activity of Daily Living Care Guide when rendering cares. The policy titled Hoyer Lift with a ,[DATE] revision date documented the Hoyer lift is to provide a safe transition from the bed to chair, when the resident is unable to bear weight, and all Hoyer lift transfers require two (2) certified/licensed staff members. Resident #2 was admitted with [DIAGNOSES REDACTED]. Review of the current Care Plan Activity Report revealed high risk for fall, bed mobility two (2) staff extensive assist and transfer two (2) staff assist via mechanical lift. Review of the [DATE] Quarterly Minimum Data Set revealed Resident #2 had severe cognitive impairment, functional limitation of one (1) upper and two (2) lower extremities, received two (2) staff dependent assist with transfers and bed mobility. Review of the [DATE] at 11:41 PM Registered Nurse Supervisor #1 progress note documentation revealed at 9:30 PM they were called to the unit to assess the resident post fall. The resident was observed in bed in the right incumbent (lying down/horizontal or resting) position with both legs flexed. The resident had dementia, was non-verbal and unable to state what happened. The assigned care staff stated they saw the resident on the floor face down by the left side of the bed while rounding and quickly grabbed the Hoyer lift and transferred the resident back to bed before calling for help. The resident was noted with a lump on the forehead, a swollen and deviated nose, appeared flushed, and had bleeding from the right nostril. The call bell was not activated at the time of fall, no fluid spills noted on the floor. Active/Passive range of motion within baseline. Vital signs within normal range. The resident's son was notified and amenable to the plan of care. 911 was called and arrived at the facility at 9:50 PM and left with the resident at 10:00 PM. Review of the undated Investigation Summary documentation revealed that on [DATE], at approximately 9:30 PM, Certified Nurse Aide #3 stated they noted the resident to be on the floor in their room when they went to administer care. Certified Nurse Aide #3 panicked and when they could not find anyone available to help, they moved the resident into their bed without help. After Certified Nurse Aide #3 moved the resident, the Licensed Practical Nurse on the unit responded and alerted the Registered Nurse Supervisor who attended to and assessed Resident #2, and per nurse assessment, Resident #2 had a 3. 5-centimeter hematoma (collection of blood under the skin) on the right side of their forehead and was bleeding from their right nostril. The Nurse Practitioner on call was notified, and the resident was transferred to the hospital. The Investigation report documented that when the resident returned from the hospital at 3:00 AM the paperwork from the hospital documented no evidence of any new fracture. CT scan (x-ray and a computer to show images on the inside of the body) of the face, head and cervical spine revealed an old [MEDICAL CONDITION] bone. The conclusion documented Certified Nurse Aide #3 was to be re-educated on policy and procedure on use of the Hoyer lift, as well as calling for help assistance in emergency situations. Included in the Investigative Summary was documentation of a typed telephone interview conducted by the Director of Nursing with Certified Nurse Aide # 3. The documentation revealed during telephone interview, Certified Nurse Aide #3 stated they were aware of Resident #2's plan of care to transfer with two-person assist as they were a Hoyer lift. Certified Nurse Aide #3 stated they panicked when they saw Resident #2 on the floor lying on their left side facing the door in the center of the room between the two (2) beds, and there was blood. Certified Nurse Aide #3 stated they had gone out into the hallway could not find anyone, so they immediately got the Hoyer lift which was in the hall and used the Hoyer lift to transfer the resident back into bed until they were able to report to the Licensed Practical Nurse on duty. Certified Nurse Aide #3 stated they were aware they should not have moved Resident #3 alone and were also aware of the policy on utilizing two assist with Hoyer lift transfers, but they panicked. Review of the [DATE] Investigation Summary documentation revealed on [DATE] at approximately 8:15 PM, Certified Nurse Aide #4 reported while turning the resident, the resident bumped their head on the bedside table. They immediately came out and looked for the nurse. Licensed Practical Nurse #3 and Registered Nurse Supervisor #1 were at the station. Both nurses entered the room, and the resident was supine (lying on the back) in bed with the head of the bed up. There was a hematoma on the left forehead and the right nostril was bleeding Ice was applied to the forehead and nostril to stop the bleeding with positive result. Neuro checks (evaluation of the nervous system) were initiated and were within normal limits. The physician was called and ordered the resident to be sent to the hospital. The documented investigation conclusion revealed based on investigation, it can be determined that a care plan violation occurred resulting in an injury. The resident was dependent with two-person assist for bed mobility and the involved aide turned and positioned the resident by themselves despite knowing the resident was an assist of two (2). On [DATE], the staff member was removed from unit duty. Review of the [DATE] at 9:34 PM Registered Nurse Supervisor #1 progress note revealed they were called to the resident's room to assess the resident. The resident was in bed in supine position with the head of the bed up. The resident had a lump on the left side of the forehead and a right nostril bleed. The assigned staff at the bedside stated that while they were turning the resident, the resident hit their head on the bedside table. Ice was applied and no sign of distress was noted. A message was left for the physician to call the facility. The resident was placed on neuro checks x 72 hours. Continue to monitor. Review of the [DATE] at 11:34 PM Registered Nurse Supervisor #1 progress note revealed they received a call from the physician with an order to send the resident to the hosp | Plan of Correction: ApprovedJuly 1, 2025 F- 689 I. The following actions were accomplished for the residents identified in the sample: Resident #2 The Resident no longer resides in the facility; therefore, no corrective action could be implemented. CNA #3 On 06/7/2024, the staff member was immediately removed from direct care responsibilities pending investigation. Staff member was terminated on 06/17/2024 CNA #4 The staff member was permanently removed from duty as of 6/7/24 II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents were identified as potentially being affected by the same practice. Together with the outside consultant, the facilitys QAPI Committee convened a Directed Plan of Correction QAPI meeting on (MONTH) 25, 2025, to discuss and conduct a Root Cause Analysis of the deficient practice identified during survey related to Accident Prevention. During this meeting, the outside consultant provided education and guidance to the Committee members on the use of a Root Cause Analysis when compliance issues are identified Please refer to corrective actions outlined in Sections II, III and IV of this Directed Plan of Correction. Unit Managers/designees will assess all residents to ensure appropriate staffing levels and supervision during ADL care is identified in the care plan. The Interdisciplinary Care Plan (IDCP) Team will review and update care plans for accuracy and completeness. Unit Managers will communicate these updates to unit staff and adjust CNA assignments accordingly. They will also verify that CNA staff are accessing and documenting care through the electronic Kiosk system. Effective 05/02/2025 education will be initiated by the Director of Nursing/designee to all staff regarding accident prevention protocols, including adherence to care plans, proper use of assistive devices and mechanical lifts, required staff presence during care, and correct response to incidents. This education will include a review of the survey findings, policy and procedure revisions, and general accident prevention. The Staff Educator/designee will continue this training until all staff have received it. Accident Prevention training will be provided for all staff on a semi-annual basis and will continue to be provided during orientation of new hires to ensure that staff are aware of their responsibility to maintain standards of practice related to accident prevention. Effective 05/05/2025 random audits will commence by Unit Managers/designees to ensure proper staffing support, staff understanding of ADL requirements, and compliance with each residents care plan. When non-compliance is identified, immediate corrective actions, including care plan revisions, staff re-education, or disciplinary measures will be taken as appropriate. CNA competencies will be completed by the Staff Educator/designee for all active CNA staff to ensure current documentation regarding ADL care, including mechanical lift usage. CNA competencies related to bed mobility and transfers, with or without mechanical lifts, will be completed by the Staff Educator/designee during new staff orientation and whenever competency concerns arise. Effective 05/07/25, the Unit Manager/Charge Nurse will audit two (2) residents receiving ADL care per shift, per unit, weekly for two (2) months, and then quarterly for an additional four (4) months. Residents who require transfer assistance with and without the use of a mechanical lift will be included in the audit sample. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, Medical Director, Director of Rehabilitation, and Director of Nursing, along with the outside consultant, reviewed and revised the facilitys policies and procedures related to: Activities of Daily Living Care Plan: Revisions emphasized adherence to directives regarding number of staff and equipment required for resident care. Fall Management: Revisions clarified appropriate response procedures when a resident falls or is found on the floor. Use of Mechanical Lifts (e.g., Hoyer): Revisions included a detailed procedure for assessment, inspection, maintenance, and training and defined staff responsibilities. Additional revisions were recommended by the outside consultant following discussion at the DP(NAME) meeting and review of the pertinent policies. The Administrator, Medical Director, Director of Rehabilitation and Director of Nursing will continue to review and revise, as needed, the facilitys policies and procedure related to accident prevention including protocols related to ADL assistance provided as per the plan of care, staff members needed to provide care/assistance including when using a mechanical lift. Additional education will be provided by the Staff Educator on Accident Prevention, minimally on an annual basis, and as needed. The Director of Nursing/designee will continue daily reviews of all Accident Incident Reports and investigation documents to determine staff compliance with the plan of care. Immediate corrective action, such as updating the plan of care, staff reeducation, or disciplinary action will be implemented as indicated. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, the QAPI Committee, co-chaired by the outside consultant, convened on (MONTH) 25, 2025, to analyze the deficiency. An audit tool was developed to monitor Nursing staff competencies and knowledge related to adherence to the plan of care, the required number of staff being present to assist with ADL care to prevent an accident, and accident response. The Unit Manager/Charge Nurse will audit two (2) CNAs providing ADL care on all shifts and units weekly for two (2) months and then monthly for an additional four (4) months. All ADL competency and knowledge audit findings related to Accident Prevention will be reported to the Administrator, Medical Director and DNS monthly. Corrective action, such as staff re-education or disciplinary action, will be implemented as indicated. The Director of Nursing will report all audit findings regarding ADL care assistance and accident prevention to the QAPI Committee monthly for six months. The compliance threshold will be 95%. If the compliance threshold is not met at the end of the 6-month period, education and auditing will continue monthly. If the acceptable compliance threshold is met at the end of the 6- month period, the QAPI Committee will determine whether and how often to continue monitoring. The Director of Nursing/designee will continue auditing all Occurrence Reports and will present trend analyses to the QAPI Committee at least quarterly for evaluation and the development of further corrective actions. Responsibility: Director of Nursing Completion Date: 06/3/2025 |