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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 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 conducted during an abbreviated survey (NY 497), the facility failed to protect a resident's right to be free from physical abuse by a nursing home staff. This was evident in one (1) out of three (3) residents (Resident #1) sampled for abuse. Specifically, on 09/07/2023 at approximately 2:15 PM the Occupational Therapist reported to the Director of Nursing that Resident #1 was observed in the dining room with a black eye. Resident #1 reported that they were punched in the eye by a crazy lady and identified Registered Charge Nurse #1 as the person who punched them in the eye on 09/06/2023 during the evening shift. Registered Charge Nurse #1 did not immediately assess Resident #1 after being told Resident was observed with discoloration to their eye. The findings include: The facility's policy and procedure on Prohibition of Residents Abuse, Neglect and Misappropriation of Property dated 03/19/2025 documented the facility residents have the right to be free from Abuse, Neglect, Exploitation and misappropriation of property. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 07/03/2023 documented Resident #1 had intact cognition. An Abuse Care Plan dated 07/05/2023 documented interventions to provide a safe and calm environment, and reduced agitation. Provide comfort, reassurance, and keep the resident safe by removing them from being annoyed by other residents. A Nurse Progress note dated 09/07/2023 at 5:29 PM by Licensed Practical Nurse #1 documented Resident #1 was observed with discoloration to their right periorbital. An assessment was done by Registered Nurse and the Emergency Medical Technician. There were no complaints of pain. Resident #1 stated they were struck, resulting in injury. A Summary of Investigation dated 09/07/2023 at 2:15 PM documented they received a call from Occupational Therapist #1 at about 2:15 PM stating Resident #1 was observed with a black eye in the dining room. The Director of Nursing was notified and immediately responded. Resident #1 was observed with a purple bruise to the right lower eye lid. Assigned Certified Nursing Assistant #1 reported that Registered Charge Nurse #1 saw Resident #1 with the purple bruise to their right lower eyelid. Registered Charge Nurse #1 did not assess Resident #1, and did not notify the Nursing Supervisor and Medical Doctor of the potential abuse. Resident #1 was interview and reported that they were punched in the eye by a crazy lady identified as Registered Charge Nurse # 1. Registered Charge Nurse #1 was interview and stated on 09/06/2023 at 6:50 PM Resident #1 slapped them on the left side of their face because they were redirecting them from entering the dining room. The dining room was mopped, and the door was closed to allow the floors to be dried. The Medical Doctor was notified and ordered an x-ray of facial bones. The x-ray results dated 09/10/2023 showed no acute fractures. An Optometry examination dated 10/09/2023 documented no changes. 911 was called and responded. Resident #1 and Registered Charge Nurse #1 was interviewed, and no charges were file. The facility concluded that there may be reasonable cause to believe alleged resident abuse, mistreatment or neglect had occurred. A physician progress notes [REDACTED]. Noted to be mild and in resolving stage. Resident #1 was not in any distress and mental status stable at baseline. There was no complaint of pain. Right periorbital ecchymoses, appears to be not of acute nature. A Radiology Report dated 09/10/2023 documented multiple views of the facial bones demonstrate no acute fractures. The orbital rims are intact. Occupational Therapist #1 is no longer employed at the facility but wrote a statement to the facility dated 09/07/2023 stating at approximately 11: 00 AM to Noon they observed Resident #1 walking out of the elevator with a black eye. This was immediately reported to Registered Charge Nurse # 1. During an interview on 03/19/2025 at 11:15 AM Resident #1 stated that a lady punched them in their eye some time ago. Resident #1 stated they slapped a lady (unable to recall identity, and the lady then punched them in their eye. Resident #1 stated they are unable to recall the time of the incident. During an interview on 03/19/2025 at 2:22 PM Registered Charge Nurse #1 stated they worked on 09/06/2023 during the day shift from 7:00 AM - 3:00 PM and did not see any discoloration on Resident #1's face. Registered Charge Nurse #1 stated they also worked late on 09/06/2023 and was leaving the unit at approximately 6:50 PM via the stairwell when they observed Resident #1 opening the dining room door to enter inside. Registered Charge Nurse #1 stated they instructed Resident #1 not to enter the dining room because the floor was wet, and Resident #1 slapped them on the left side of their face. Registered Charge Nurse #1 stated Resident #1 began to curse at them stating they had no right to stop them. Registered Charge Nurse #1 stated they screamed out for help and the evening shift medication nurse (Licensed Practical Nurse #1) came over and escorted Resident #1 away. Registered Charge Nurse #1 stated they were late leaving work and did not initiate an incident report, however, they saw the Assistant Director of Nurse in the lobby and reported the incident to them. Registered Charge Nurse #1 stated they did not see any redness or discoloration on Resident #1's face when they arrived at work on 09/27/2023 and conducted rounds during the morning shift. Registered Charge Nurse #1 stated at approximately 11:00 AM - 12:00 PM on 09/27/2023, Occupational Therapist #1 informed them Resident #1 had redness and discoloration on their face. Registered Charge Nurse #1 stated they did not assessed Resident #1, and did not get close to the Resident because the Resident slapped them the prior evening. Registered Charge Nurse #1 stated they did not report the discoloration to neither the Nursing Supervisor nor the Medical Doctor. Registered Charge Nurse #1 stated Occupational Therapist #1 took Resident #1 off the floor to the Director of Nursing office. Registered Charge Nurse #1 stated the Police Officers interviewed them, and they explained the slapped from the previous evening and showed the Officers the swelling on the left side of their face. Registered Charge Nurse #1 stated the Police Officers left and did not file a report. Registered Charge Nurse #1 stated they did not punch or hit Resident #1 in their face. During an interview on 04/04/2025 at 1:00 PM, Licensed Practical Nurse #1 stated they worked as the medication nurse on 09/06/2023 from 3:00 PM - 11:00 PM. Licensed Practical Nurse #1 stated at approximately 6:30 PM - 7:00 PM while they were administering medication, they heard loud voices (Resident #1 and Registered Charge Nurse #1) talking and went to see what was happening. Licensed Practical Nurse #1 stated they did not observe any physical contact between Resident #1 and Registered Charge Nurse #1; however, Registered Charge Nurse #1 informed them Resident #1 slapped them. Licensed Practical Nurse #1 stated they escorted Resident #1 away and Registered Charge Nurse #1 went down the stairs. Licensed Practical Nurse #1 stated they did not see any discoloration on Resident #1's face at time. During an interview on 03/21/2025 at 12:27 PM Certified Nursing Assistant #1 stated they worked on the unit on 09/07/2023 and was assigned to the dining room during the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #1 stated at approximately 7:20 AM on 09/07/2023 while they were serving breakfast, they observed discoloration and redness to Resident #1's right lower eye lid. Certified Nursing Assistant #1 stated they did not report the discoloration to the nurse because Registered Charge Nurse #1 and the other Certified Nursing Assistants | Plan of Correction: ApprovedApril 29, 2025 Element#1 What corrective actions(S) will be accomplished for those residents found to have been affected by the deficient practice Residents #1 who was affected by this deficient practice was assessed by RN Supervisor (RNS), PMD and Psychiatrist. Right periorbital xray was ordered and result showed no fracture. Accused RN was immediately removed from duty. Completed 4/17/2025 Element #2 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 under the care of accused RN had the potential to be affected by the deficient practice, consequently, upon report of occurrence on 9/7/2023, the accused RN was immediately removed from duty and employment subsequently terminated. Cognitively intact residents who were under the care of accused RN will be interviewed and assessed for abuse or inappropriate interactions. Resident who are cognitively impaired, their NOK will be interviewed instead. Completed 6/3/2025 Element#3 What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Facility Abuse prevention policy and procedure was reviewed and revised to include, staff accused of abuse must be removed from duty immediately All employees, will be monitored by their respective department head to ensure they are not abusing residents. Specifically, unit CNA, LPN and RN will be monitored by RN Supervisor. ADNS will supervise RNS for any inappropriate or abusive interactions with residents. Employees identified with behaviors or negative interactions that equates to abuse will be removed from duty immediately. All resident will be monitored by unit RN Supervisor and Social Worker to ensure they are not abused by staff. All staff who directly interact with resident- such as nursing, medical, housekeeping, social work, activities, rehabilitation and administration- will be re-inservice on abuse prevention by ADNS and/or their direct supervisor. Social Work Director and/or designee will attend monthly resident council meeting to educate resident on procedure for promptly reporting abuse DNS will monitor for sustained compliance of staff abuse prevention education and observation to ensure all residents are free from staff abuse. Completed by 5/31/25 Element#4 How the corrective actions(s) will be monitored to ensure the deficient practice will not recur ÔÇ£ what quality assurance program will be put into practice Social Worker will audit/interview 5 residents weekly to assess comfort with caregivers and/or report of abuse and report to DNS and/or Administrator of their findings . Negative findings will be addressed promptly. ADNS will conduct weekly audit of direct staff interaction with resident on unit and report to DNS and/or Administrator of their findings; Negative findings will be addressed promptly. Audit findings will be reported and reviewed at QAPI weekly x 2 weeks; monthly x 2 months, then quarterly thereafter. Completed by 5/31/2025 Element #5 The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing and/or designee Date __6/3/2025______________ |