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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during abbreviated Survey (NY 611, NY 114), the facility did not protect a resident's right to be free from physical abuse by nursing home staff. This was evident in two out of seven residents sampled (Resident #1 and #4). Specifically, on 12/04/2024 at 10:37 AM, the facility's surveillance camera recording was reviewed and showed on 11/23/2024 at 3:00 PM, there was a physical altercation between Resident #1 and Security Guard #1. The facility's investigative notes dated 11/27/2024, documented on 11/23/2024, Registered Nurse Supervisor #1 and Registered Nurse #1 observed Security Guard #1 grabbed Resident #1 by the collar of Resident #1's clothes and held Resident #1 against the wall. There were no injuries to Resident #1. Specifically, on 12/03/2024 at 9:30 PM, the Facility's Incident Report documented Certified Nursing Assistant #3 reported to Registered Nurse #3 that Resident #4 was combative and refused personal care. Registered Nurse #3 accompanied Certified Nursing Assistant #3 to provide personal care to Resident #4. Resident #4 agreed to receive personal care but while attempting to take Resident #4's pants off, Resident #4 kicked at Certified Nursing Assistant #3. Certified Nursing Assistant #3 used their hand to block Resident #4 from kicking Certified Nursing Assistant #3 in the face. Registered Nurse #3 reported they saw Certified Nurse Assistant #3 hit Resident #4 with the back on their right hand. The findings are: The Facility's Policy on Abuse Prohibition revised 04/2022, assured all residents and families that the facility will take steps within its control to prevent Abuse, Mistreatment, Adverse Events, Neglect, Exploitation, and Misappropriation of Resident Property. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE], documented that Resident #1's cognition was intact and Resident #1 was at risk for wandering. The facility's surveillance camera was reviewed on 12/04/2024 at 10:37 AM, with the Acting Administrator, Director of Nursing and Security Guard #2. The surveillance video recording showed: No date recorded for incident that occurred on 11/23/2024 at 3:00 PM. At 00:18 seconds to 00:31 seconds, Resident #1 was seen walking down the hallway of a locked nursing unit. Certified Nursing Assistant #1 and Certified Nursing Assistant #2 (who is providing 1:1 supervision of Resident #1) were talking to Resident #1. Resident #1 stopped in the middle of the hallway. At 00:32 seconds to 00:37 seconds, Registered Nurse #1 was walking down the hallway to meet Resident #1. Registered Nurse Supervisor #1 was standing in the hallway with Certified Nursing Assistant #1 and #2. At 00:39 seconds to 00:43 seconds, Certified Nursing Assistant #1 was trying to redirect Resident #1. Resident #1 continued to walk and make hand movements toward Registered Nurse #1. Certified Nursing Assistant #2 and Registered Nurse Supervisor #1 continued to follow Resident #1. At 00:46 seconds to 00:56 seconds, Registered Nurse #1, Certified Nursing Assistant #2, and Registered Nurse Supervisor walked behind Resident #1 who is proceeding to the emergency exit door. At 00:56 seconds, Security Guard #1 walking towards the emergency exit door. At 01:19 seconds to 01:23 seconds, Security Guard #1 approached Resident #1 and stood on left side of Resident #1. Registered Nurse #1, Certified Nursing Assistant #2, and Registered Nurse Supervisor #1 were standing close to Resident #1. At 01:35 seconds to 01:42 seconds, a physical altercation taking place between Resident #1 and Security Guard #1 (unable to view clearly what was going on in the video). The video did not capture clearly what was happening. At 01:43 seconds to 01:49 seconds, the three staff went to Resident #1 and Security Guard #1. At 01:51 seconds to 01:53 seconds two more nursing staff ran to assist them. At 01:56 seconds, Resident #1 and Security Guard #1 were separated. At 01:07 seconds, Security Guard #2 approached the hallway. At 02:49 seconds to 02:59 seconds, Security Guard #1 and Security Guard #2 walked down the hallway and passed through an exit door to the main lobby. At 03:11 seconds, (video was too blurry to view) the emergency exit door opened, and staff followed. (As per interview with staff, Resident #1 opened and exited through the emergency exit door). They (staff) were able to encourage Resident #1 to return to unit. The Facility's Investigation dated 11/27/2024 documented on 11/23/2024 at 3:00 PM, there was an employee to resident altercation resulting in grabbing of Resident #1's collar. The Security Guard #1 (the perpetrator) was removed from duty immediately and reported to their Contract Agency. Resident #1 was transferred to hospital for evaluation of uncontrollable agitative behavior. Based on investigation there was reasonable cause to believe alleged physical abuse occurred. The 911(Emergency number) was called and four Police Officers and Emergency Medical Service responded. The New York City Police Officers did not arrest Security Guard #1 or make any report. During an interview on 12/04/2024 at 10:30 AM, Resident #1 stated they do not remember any incident that happened to them. During an interview 12/04/2024 at 11:55 AM, Security Guard #1 stated they heard the locked unit exit door alarm sounded and saw the staff running in the hallway. Security Guard #1 stated they responded immediately and observed Resident #1 going to the emergency exit door. Security Guard #1 stated they approached Resident #1 and told them that they cannot leave. Resident #1 told Security Guard #1 to leave them alone or else they will punch them (Security Guard #1). Security Guard #1 stated Resident #1 suddenly punched them in their face. Security Guard #1 stated they reacted and grabbed the neck of Resident #1's clothes and held Resident #1 against the wall. Security Guard #1 stated they did not have any intention of hurting Resident #1. Security Guard #1 stated they were aware that they were not supposed to grab Resident #1 and believed that it was considered abuse. During an interview on 12/04/2024 at 12:22 PM, Registered Nurse Supervisor #1 stated they responded to the alarm and saw Resident #1 walking down the hallway towards the emergency exit door. Registered Nurse Supervisor #1 stated there were three staff members trying to redirect Resident #1. Registered Nurse Supervisor #1 stated while Security Guard #1 was talking to Resident #1, they (Registered Nurse Supervisor #1) heard Resident #1 saying to Security Guard #1, if you touch me, I will kill you. Registered Nurse Supervisor #1 stated they did not witness Resident #1 punch Security Guard #1 but observed Security Guard #1 grab Resident #1 by the collar of Resident #1's clothes and held Resident #1 against the wall. Registered Nurse Supervisor #1 stated they immediately separated Security Guard #1 and Resident #1. Registered Nurse Supervisor #1 stated Resident #1 breached the emergency exit door and proceeded to go outside and they and two other staff members followed Resident #1, and they were able to redirect Resident #1 back on the nursing unit. Registered Nurse Supervisor #1 stated they called Emergency Medical Services and Law Enforcement who responded. No reports was made. Registered Nurse Supervisor #1 stated Resident #1 refused body check, but there were no visible injuries observed and Resident #1 did not complain of pain. Resident #1 was transferred to the hospital for evaluation by the Emergency Medical Services. Resident #1 was discharged from the emergency room and returned to the facility on [DATE]. During an interview on 12/04/2024 at 3:30 PM, Registered Nurse #1 stated the Security Guard #1 tried to control Resident #1 but Resident #1 was too strong. Registered Nurse #1 stated they saw Resident #1 raised their right hand but did not observe if they (Resident #1) punch Security Guard #1. Registered Nurse #1 stated they saw Security Guard #1 holding Resident #1 by the collar against the wall. Registered Nurse #1 stated they intervene and separate them. During an interview on 12/05/2024 at 12:55 PM, Director of Nursing stated Resident #1 had a history of [REDACTED]. The Director of Nursing stated Resident #1 was placed on one to one since Resident #1 was admitted to facility on 09/18/2024. Director of Nursing stated Resident #1 tried to elope by pushing the locked nursing unit door and was unable to be redirect by staff despite encouragement. Director of Nursing stated the video and staff statements were reviewed and concluded that physical abuse occurred. The Director of Nursing stated, Security Guard #1 was removed from the schedule immediately and reported to their Contract Agency not to returned to the facility. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented that Resident #1's cognition was intact. There were no mood or behavioral symptoms documented. The Facility's Incident Report dated 12/03/2024 at 9:30 PM, documented Certified Nursing Assistant #3 reported to Registered Nurse #3, Resident #4 was combative and refused care. Registered Nurse #3 accompanied Certified Nursing Assistant #3 to provide care to Resident #4. Resident #4 agreed to receive the care but while attempting to take Resident #4's pants off, Resident #4 kicked at Certified Nursing Assistant #3. Certified Nursing Assistant #3 used their hand to block Resident #4 from kicking Certified Nursing Assistant #3 in the face. Registered Nurse #3 reported observed Certified Nurse Assistant #3 hit Resident #4 with the back on the right hand. The Registered Nurse Supervisor #2 Nursing Note dated 12/04/2024 at 1:23 AM, documented Resident #4 was assessed and there were no visible injuries bruises or discoloration. Resident #4 denied any pain or discomfort. Certified Nursing Assistant #3 was immediately removed from the unit pending the investigation. Resident #4's family member was notified. Reviewed of behavioral notes dated 10/28/2024, 11/01/2024, and 11/10/2024, documented Resident #4 refused personal care and was aggressive towards staff. During an interview with Resident #4 on 12/04/2024 at 12:30 PM, Resident #4 said they do not recall any incident. During a telephone interview on 12/04/2024 at 12:58 PM, Certified Nursing Assistant #3 stated Resident #4 has aggressive behavior during care and required two persons to be in the room while providing personal care. Certified Nursing Assistant #3 stated Resident #4 asked to be put in bed, so Certified Nursing Assistant #3 called Certified Nursing Assistant #4 to assist. Certified Nursing Assistant #3 and Certified Nursing Assistant #4 transferred Resident #4 to the bed. Resident #4 then refused to remove their clothes and said they are cold. Certified Nursing Assistant #3 stated they informed Registered Nurse #3 that Resident #4 refused to take their clothes off for personal care because Resident #4 said they are cold. Certified Nursing Assistant #3 stated they served Resident #4 dinner included a hot drink and covered Resident #4 with an extra blanket. Certified Nursing Assistant #3 stated around 9:00 PM, they went to Resident #4's room with the Registered Nurse #3, and Registered Nurse #3 informed Resident #4 that Certified Nursing Assistant #3 was going to provide personal care. Resident #4 agreed and did not want their top to be removed. Certified Nursing Assistant #3 stood at foot of the bed to take off Resident #4's pants, Resident #4 attempted to kick Certified Nursing Assistant #3 on the face. Certified Nursing Assistant #3 stated they blocked Resident #4 with their hand to stop Resident #4 from kicking them (Certified Nursing Assistant #3) on the face. Registered Nurse #3 was standing at the head of the bed and told Resident #4 they are not supposed to hit the staff. Certified Nursing Assistant #3 stated Registered Nurse #3 told them (Certified Nursing Assistant #3) they are not supposed to hit Resident #4. Certified Nursing Assistant #3 stated they told Registered Nurse #3 they did not hit Resident #4, but they were protecting themselves from Resident #4 kicking their face. Certified Nursing Assistant #3 stated they have been working at the facility for eight years and they would never do such a thing. Certified Nursing Assistant #3 stated they have worked on the dementia unit for four years and they were trained on how to care for residents with behavior. Certified Nursing Assistant #3 stated they were suspended after giving their statement. During an interview on 12/04/2024 at 4:08 PM, Registered Nurse #3 stated Certified Nursing Assistant #3 reported to them that they will not give Resident #4 care because Resident #4 hit them. Registered Nurse #3 stated they told Certified Nursing Assistant #3 they will come and observed when Certified Nursing Assistant #3 is providing personal care to Resident #4. Registered Nurse #3 stated Certified Nursing Assistant #3 called them at approximately 9:30 PM, to provide personal care to Resident #4. Registered Nurse #3 stated they went with Certified Nursing Assistant #3 into Resident #4's room to observe Certified Nursing Assistant #3 given care. Registered Nurse #3 stated Certified Nursing Assistant #3 stood by Resident 4#'s right side of the bed across from Registered Nurse #3 on the left side of the middle of the bed. Registered Nurse #3 stated before Certified Nursing Assistant #3 starting to provide personal case, Resident #4 said do not take off my sweater, Certified Nursing assistant #3 started to remove Resident #4's sweatpants, Resident #4 suddenly used their right hand to hit Certified Nursing Assistant #3 's left arm. Certified Nursing Assistant #3 hit Resident #4 back on the right hand. Registered Nurse #3 stated they told Certified Nursing Assistant #3 they cannot hit Resident #4 and to stop providing care and leave Resident #1's room. Registered Nurse #3 stated Certified Nursing Assistant #3 immediately stopped and left the room and they called the Registered Nurse Supervisor #2 to the Nursing unit. On 12/03/2024, The temperature of Resident's #4's room was 77.6 degrees Fahrenheit. During an interview on 12/09/24 at 3:30 PM, the Director of Nursing stated they interviewed Certified Nursing Assistant #3, who denied hitting Resident #4. The Director of Nursing stated according to Certified Nursing Assistant #3, Resident #4 attempted to kick them while they (Certified Nursing Assistant #3) were assisting Resident #4, and they used their hands to block the attempt. The Director of Nursing stated Certified Nursing Assistant #3 demonstrated this action to them (Director of Nursing). The Director of Nursing stated they interviewed Registered Nurse #3 who said Certified Nursing Assistant #3 hit Resident #4 on their right hand appropriately three times in rapid succession. The Director of Nursing stated Registered Nurse #3 said they instructed Certified Nursing Assistant #3 to leave Resident #4's bedside and called the Registered Nursing Supervisor #1 to report the incident. The Director of Nursing stated they conducted their investigation based on staff 's statements, and interviews, and concluded a physical altercation did occur between Resident #4 and Certified Nursing Assistant #3. This was physical abuse of Resident #4. 10 NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedDecember 27, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action for Affected Resident/Area A. Immediately after the incident, Resident #1 was assisted to safety on the Unit for RN Assessment. Resident #1 refused the body check, but the Supervisor reported that no visible injury was noted and there were no complaints of pain. The Designated Representative was informed and the Physician Ordered to transfer the Resident out to the Hospital for further evaluation of uncontrolled agitative behavior. The Security Guard, who did not follow the Facility?ÇÖs Policy and Procedure for ?Ç£Abuse Prohibition?Ç¥ was immediately removed from duty and his assignment at the Home was terminated by the Contract Vendor. B. Immediately after the incident, Resident #4 was assessed by the RN. There were no visible signs of injury or complaints of pain reported. The Certified Nursing Assistant who did not follow the Facility?ÇÖs Policy for ?Ç£Abuse Prohibition?Ç¥ was immediately removed from direct Resident care duties and placed on Administrative Leave pending an Investigation. II. Identification of other Areas/Residents Potentially Affected. ?Çó The Facility respectfully states that no other residents were identified with Abuse, Neglect, or Mistreatment concerns. The Director of Nursing/Designee performed an Audit of all other residents, to ensure that they have an Abuse Prevention/Prohibition and Resident Centered Care Plan in place. Any Resident identified with missing alleged Abuse Care Plans will be promptly updated. ?Çó The Facility will provide comprehensive ?Ç£Abuse prohibition?Ç¥ re-training for all staff members to effectively manage and support residents exhibiting behaviors associated with dementia and other behaviors. Rein-service/Competency will continue until all employees are re-trained. III. Address what measures will be put in place or Systemic Change made to ensure that the Deficient practice will not Recur/System change and Measure to prevent Recurrence. ?Çó The Facility changed the Systems for monitoring ?Ç£Abuse Prohibition?Ç¥ to include a process that during Shift Change Huddles, the Charge Nurse will also reinforce adherence to the ?Ç£Abuse Prohibition?Ç¥ Policy and practices and remove triggers for residents who have potential for escalating verbal outburst or violent physical aggression. ?Çó The Home will select front-line staff to serve as ambassadors in specialized Dementia Care and Behavioral Management, who will provide support and guidance to other team members. ?Çó The Facility?ÇÖs Policy and Procedure for ?Ç£Abuse Prohibition?Ç¥ was reviewed by the Acting Administrator and was found to be compliant. All current employees will be rein-serviced immediately on the Policy and annually thereafter. New employees will be In-service during Orientation. Lesson Plan will include, but will not be limited to: ?Çó The Facility will not knowingly and intentionally hire individuals found guilty of Abuse, Mistreatment of [REDACTED]. ?Çó Employees shall adhere to the reporting mechanism as outlined in the law and regulations. ?Çó Employees are made aware that any derogatory language or remarks towards Residents and any other potential Abuse, Neglect issues will lead to immediate suspension/termination. ?Çó The Facility will train staff to safely care for combative residents, emphasizing de-escalation techniques and ensuring that they do not retaliate to physical aggression. ?Çó The Facility requires that Potential Abuse cases are reported and investigated immediately once brought to the attention of a Supervisor. ?Çó Employees are instructed on appropriate and safe interventions of care to be used with aggressive residents with behaviors. ?Çó Employees shall report occurrences that may be interpreted as acts of Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. ?Çó Ensuring staff understanding of Residents?ÇÖ behaviors that could lead to physical violence, and Behavioral Management measures to de-escalate such behaviors. ?Çó Licensed staff members are educated on how to document and fully describe unusual events that could be interpreted as a situation of Potential Abuse. ?Çó Administrative Management and Supervisory personnel monitor staff interaction with residents on an ongoing basis to ensure residents?ÇÖ safety. In-service and Competencies will be filed in the employees Personnel History Folder for reference and validation. IV. How does the Facility plan to monitor its performance to make sure that Solutions are Sustained/Monitoring of Corrective Actions ?Çó The Director of Nursing and the Director of Social services developed an ?Ç£Abuse Prohibition Compliance Audit Tool?Ç¥ to identify high risks resident for alleged potential abuse, and staff interventions for such behaviors. ?Çó The Audit Tool will be used Daily by the Associate Director of Nursing/Designee and the Social Workers/Designee, to monitor and document alleged cases of Potential Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. Any case found out of compliance will warrant an immediate on the spot correction/rein-service by the Supervisor, followed by a formal Report, employee Statements, and an Investigation. ?Çó The Director of Nursing and the Director of Social Services will review the Audit Tool Weekly for compliance. The Tool will be filed in a Binder in the Nursing Administration Office after it is reviewed, for reference and validation. 1V. QA Monitoring ?Çó The person responsible to correct this issue is the Director of Nursing and the Director of Social Services. The Associate Director of Nursing/Designee will report findings Monthly to the QAPI Committee for 12 Months. |