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Scope: Isolated
Severity: Actual harm has occurred
Citation date: December 16, 2024
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 375 & NY 928), the facility failed to ensure that a resident received adequate supervision to prevent accidents. This was evident for two (2) out of two (2) residents (Resident #1 & Resident #2). Specifically, On [DATE] at 5:30 AM, Certified Nurse Assistant #1 transferred Resident #1 from their bed to the wheelchair and Resident #1 fell . Resident #1 required two-person assist with mechanical lift. Resident #1 was assessed by Nursing Supervisor #1 and was observed with an opened purpura (purple-colored spots and patches on the skin) on their left lower extremity. A nursing note dated [DATE] documented Resident #1 was transferred to the emergency room at 8:38 AM on [DATE] after being observed with decreased oxygenation and breathing with their abdominal muscles. Emergency Department Provider's note, by a Doctor of Osteopathic Medicine, dated [DATE] at 9:27 AM, documented the following: fractured right proximal tibia and fibula, fractured left proximal tibia, fractured left Distal Tibia/Fibula (two long bones in the lower left that connect the knee and ankle), and bimalleolar fracture (involved both inner and outer ankle bone) to the left ankle. Resident #1 was pronounced deceased in the hospital on [DATE] at 12:25 AM. On [DATE] at 9:00 AM, Certified Nurse Assistant #3 left Resident #2 unattended on the toilet and Resident #2 fell in the bathroom. A nursing note dated [DATE] at 10:51 AM, by Licensed Practical Nurse #2, documented Resident #2 was observed lying on their right side on the bathroom floor with a lump on the right side of their head with some blood. Tylenol 650 milligrams administered for pain. Resident #2 was transferred to the hospital for a Computed Tomography scan (a medical imaging test) of the head. A hospital After Visit Summary dated [DATE] - [DATE] documented bruising on Right forehead. This resulted in actual harm to Resident #1 and Resident #2 that was not Immediate Jeopardy. The findings include: The Policy and Procedure titled Accident/Incident Reporting dated ,[DATE], was revised on ,[DATE]. The policy documented it is the policy of the facility to promote resident/patient safety through staff education and provide a safe environment by identifying and eliminating risk without compromising independence. The facility shall ensure that the facility's environment remains free of accident hazards as possible, and that each resident receives adequate supervision and assistive devices to prevent occurrences. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated [DATE], documented Resident had impaired cognition. A Briggs Fall Risk Evaluation dated [DATE] documented Resident #1 was assessed for fall and scored a total of 20 points indicating High Risk. A Fall Care Plan created on ,[DATE] documented interventions to maintain plain pathway free of obstacles, keep personal items (eyeglasses and television remote control) within reach, and to keep bed/wheelchair in locked position. Resident Nursing Instructions dated [DATE] to [DATE] documented Resident #1 as totally dependent and required two-persons for physical assist with mechanical lift. A Nursing Progress Note dated [DATE] at 5:30 AM, written by Nursing Supervisor #1, documented at around 5:30 AM, Resident #1 was observed on the floor (in their room) with an opened purpura to their left lower extremity. There were no changes in range of motion. Xeroform (mesh dressing infused with [MEDICATION NAME]) treatment was applied. Resident #1's vital signs were taken; a head-to-toe assessment was done, and Resident #1 was transferred back to bed. The Medical Doctor was notified and ordered an X-ray of bilateral knee and pelvis. The facility's Incident Investigation Report dated [DATE] documented at 5:30 AM, Certified Nursing Assistant #1 assisted Resident #1 out of bed and Resident #1 went down on the floor mat on both knees. Resident #1 was assessed with [REDACTED]. Certified Nursing Assistant #1 was removed from the unit and the Director of Nursing was immediately notified. The investigation concluded that Certified Nursing Assistant #1 took the wrong resident out of bed and violated the plan of care. The facility Incident Investigation also documented that on [DATE] at around 7:15 AM, Resident #1 was found lying in bed by Licensed Practical Nurse #2. Resident #1 was unresponsive, breathing with their abdominal muscles, and their face was pale. The Medical Doctor was on the unit and was called to assessed Resident #1. The Medical Doctor ordered for Resident #1 to be transferred to the hospital for further evaluation. The investigation also concluded there was reasonable cause to suspect resident abuse, neglect, or mistreatment had occurred. A nursing note, by Licensed Practical #2, dated [DATE] at 10:54 AM documented Resident #1 left for the hospital at 8:38 AM. There was no disposition note in the medical record. Licensed Practical Nurse #1 provided the facility with a written statement dated [DATE]. The statement documented Licensed Practical Nurse #1 was the charge nurse on the 11:00 PM to 7:00 AM shift on [DATE]. Licensed Practical Nurse #1 gave Certified Nurse Assistant #1 a printed assignment with residents who were to be taken out of bed. Licensed Practical Nurse #1 documented at around 5:30 AM (on [DATE]), while they were giving medications, they saw Certified Nurse Assistant #1 walking towards a room, and they followed Certified Nurse Assistant #1 into Resident #1's room. Licensed Practical Nurse #1 saw Resident #1 kneeling on the floor mat next to their bed holding onto their wheelchair. Licensed Practical Nurse #1 immediately called Nursing Supervisor #1, who assisted Resident #1 back to their bed via mechanical lift. Resident #1 had an abrasion to their left leg. An order was given to clean the area with normal saline, apply Xeroform, and wrap with Kling. Resident #1 was stable after the incident. A Hospital Emergency Department Provider's Note, by the Doctor of Osteopathic Medicine, dated [DATE] at 9:27 AM to [DATE], documented Resident #1 is being treated for [REDACTED]. Resident #1 had sustained a trauma by being dropped in nursing home with bilateral lower extremity fractures, these fractures are considered non-operative per the orthopedic surgery team. A Computer Tomography scan was documented and showed Resident #1 sustained tibia/fibula fracture right proximal tibia and fibula, fracture left proximal tibia, left distal tibia/fibula fracture, and bimalleolar fracture left ankle. Mild swelling about both knees and painful response with palpation about the leg just below the joint lines on the right was also noted. Resident #1 was pronounced deceased at 12:25 AM on [DATE]. Reported to the New York City Medical Examiner office on 12:31 AM. Resident #1's adult child declined an Autopsy. During a telephone interview on [DATE] at 12:50 PM, Certified Nurse Assistant #1 stated they worked on [DATE] on the 11:00 PM to 7:00 AM shift with Licensed Practical Nurse #1 and another Certified Nursing Assistant. Certified Nursing Assistant #1 stated that Licensed Practical Nurse #1 gave them their assignment on a piece of paper. Certified Nurse Assistant #1 stated they lost the piece of paper with their assignment. Certified Nurse Assistant #1 stated Licensed Practical Nurse #1 did not explain to them that when there are only two Certified Nurse Assistants on the unit, they do not take the residents out of bed. Certified Nursing Assistant #1 stated Resident #1 was not on their assignment and that they took the wrong resident out of bed. Certified Nurse Assistant #1 stated they should have taken the resident from the A-Bed instead of the B-Bed (Resident #1). Certified Nurse Assistant #1 stated while they were taking Resident #1 out of their bed, they were also positioning the wheelchair under the resident. Certified Nursing Assistant #1 stated the wheelchair moved, and Resident #1 fell on the floor. Certified Nursing Assistant #1 stated Resident #1 had a cut and some bleeding on their leg and got Licensed Practical Nurse #1. Certified Nurse Assistant #1 stated they worked for an agency, and they were not trained by the facility to use the Kiosk (a piece of electronic equipment where Certified Nursing Assistants review their assignment before caring for a resident). Certified Nursing Assistant #1 stated they did not ask anyone for assistance. Certified Nurse Assistant #1 stated they were not aware Resident #1 was a two-person transfer with the mechanical lift and that Licensed Practical Nurse #1 did not give them report. Certified Nurse Assistant #1 stated they became aware of Resident #1's plan of care when Licensed Practical Nurse #1 came into Resident #1's room and assisted with transferring Resident #1 back into the bed. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 cleaned Resident #1's cut. Certified Nurse Assistant #1 stated they did not receive any training on the facility's policy and procedures, no training on abuse, no training on how to use the Kiosk to access their assignment. During a telephone interview on [DATE] at 03:37 PM, Licensed Practical Nurse # 1, stated that they do not recall the alleged incident and it was a long time ago and ended the interview. During a telephone interview on [DATE] at 01:43 PM, Nursing Supervisor #1 stated on [DATE] on the 11:00PM to 7:00 AM shift, they were called to assess Resident #1 who had fallen. Nursing Supervisor #1 stated when they arrived at Resident #1's room, they observed Resident #1 lying on their back on the floor mat next to their bed. Nursing Supervisor #1 stated Resident #1 was assessed to be alert, confused, not in any distress, but was unable to give an account of the incident. Nursing Supervisor #1 stated Resident #1 had no complaints of pain, had a skin tear to the left lower extremity with no deformities observed. Nursing Supervisor #1 stated they assisted Resident #1 back to the bed with the mechanical lift and the physician was notified. Nursing Supervisor stated wound care was done and a report was given to the incoming shift. Nursing Supervisor #1 stated they left Resident #1 in no acute distress. During an interview on [DATE] at 01:45 PM, Licensed Practical Nurse #2 stated during the 7:00 AM rounds, at around 07:15 AM (on [DATE]), they observed Resident #1 lying in bed, unresponsive, breathing with their abdominal muscles and face pale. Licensed Practical Nurse #2 stated the physician was on the floor and was called to assess Resident #1 who was placed on a non-rebreather oxygen mask and vital signs taken. Licensed Practical Nurse #2 stated Resident #1 was assessed to have had a dressing on their left lower leg due to a previous skin tear. Licensed Practical Nurse #2 stated a nursing supervisor was called (do not recall name), and an Intravenous fluid drip was started. Licensed Practical Nurse #2 stated the physician ordered Resident #1 to be transferred to the hospital via 911. Licensed Practical Nurse #2 stated Resident #1 was bedbound and required two-person assist with mechanical lift transfer. During a telephone interview on [DATE] at 2:36 PM, the Director of Nursing stated Resident #1 was found on their knees at the bedside after Certified Nurse Assistant #1 attempted to transfer Resident #1 out of bed. The Director of Nursing stated Certified Nursing Assistant #1 was not given any instructions to take Resident #1 out of bed. The Director of Nursing stated they learned through a third party that Resident #1's adult child reported Resident #1 expired in the hospital from broken bones. The Director of Nursing stated Resident #1 was not assessed to have any broken bones, prior to going to the hospital. During a telephone interview on [DATE] at 12:13 PM, the Medical Doctor stated they did not recall the actual accident. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #2 had severe cognitive impairment. A Briggs Fall Risk Evaluation created on [DATE] showed documentation that Resident #2 was assessed for fall and scored 9. The form did not indicate level of fall risk. A Fall Risk Care Plan dated [DATE] documented interventions to follow toileting plan as appropriate, keep bed/wheelchair in locked position, and bed in lowest position when in bed. The Care Plan was updated [DATE] post incident. An Activity of Daily Living Care Plan dated from ,[DATE] revealed Resident #2 required extensive assist of one-person. There was no documented evidence on the Fall Risk Care Plan and the Activity of Daily Living Care Plan indicating Resident #1 should not be left alone in the bathroom prior to the accident. The instructions were entered after the accident on [DATE]. The Resident Certified Nursing Assistant Documentation History Detail from [DATE] through [DATE] documented Resident #2 required extensive assist of one-person for toilet use and transfers. There were no documented instructions for staff to not leave Resident #2 in the bathroom unattended. by themself on the toilet or in the bathroom. A Progress Note (nursing) dated [DATE] at 9:46 AM, by Nursing Supervisor #2, documented they observed Resident #2 lying on their right side in the bathroom. Resident #2 had a hematoma (collection of blood outside of blood vessels that forms due to injury or trauma) on the right side of their forehead with a small amount of sanguinous (fluid contains both blood and liquid) drainage. Resident #2 was transferred to the hospital. The facility Accident/Incident Report dated [DATE] at 9:00AM, documented according to Certified Nursing Assistant #3 they had Resident #2 on the toilet and left to put an empty denture cup on the nightstand in the resident's room. Certified Nursing Assistant #3 stated Resident #2 was screaming and demanding they put the cup back on the nightstand. Certified Nursing Assistant #3 heard a sound and when they entered the bathroom, Resident #2 was lying on their right side on bathroom floor. Assessment revealed Resident #2's head was touching the floor and Resident #2 had a hematoma on the right side of their forehead. Resident #2 was confused and was unable to explain what had occurred. Ice pack and dressing applied, and neuro check initiated. On [DATE], Resident #2 was transferred to the emergency room for Computed Tomography scan of the head and bilateral hip and pelvis x-rays. The investigation concluded Certified Nursing Assistant #3's actions were not intentional; however, Certified Nursing Assistant #3 violated the facility policy by leaving Resident #2 unattended in the bathroom. There was no reasonable cause to suspect any Resident Abuse, Neglect, or Mistreatment. The investigation also revealed Resident #2 had a Computed Tomography scan of the head that revealed subdural hematoma (bleeding near the brain). There was no documented evidence in facility policy for staff not to leave residents in the bathroom or on the toilet by themselves prior to the accident on [DATE]. There was a lesson plan dated [DATE] with CNA signature on in-service sheet stating not to leave resident alone in bathroom. A Hospital emergency room Visit document dated [DATE], documented Resident #2 was transferred back to the facility with primary [DIAGNOSES REDACTED]. A Nursing Progress Note dated [DATE] at 8:35 PM, documented Resident #2 was readmitted from the hospital with primary [DIAGNOSES REDACTED]. Assessment revealed ecchymosis on right knee, ecchymosis on upper right hand, and ecchymosis (a medical term for a bruise, which is a discoloration of the skin caused by leakage of blood from damaged blood vessels into surrounding tissues) and swelling over the right eyebrow with dried blood. During an interview on [DATE] at 2:10 PM, Certified Nurse Assistant #3 stated they put Resident #2 on the toilet and put the denture cup on the bathroom sink and Resident #2 began yelling demanding Certified Nursing Assistant #3 put the denture cup on their bedside table. Certified Nurse Assistant #3 stated they explained to Resident #2 that they could not leave them on the toilet and Resident #2 kept yelling for Certified Nursing Assistant #3 to put the denture cup on the bedside table. Certified Nursing Assistant #3 stated they did what Resident #2 asked and then they heard a fall like noise and found Resident #2 on the bathroom floor. Certified Nursing Assistant #3 stated they called for Licensed Practical Nurse #3 to check Resident #2. Certified Nursing Assistant #3 stated Resident #2 had a bump and bleeding on their head. During an interview on [DATE] at 11:00 AM, Licensed Practical Nurse #3 stated Certified Nurse Assistant #3 called them to Resident #2's bathroom and they observed Resident #2 lying next to the toilet with a hematoma to the right side of their face. Licensed Practical Nurse #3 stated Resident #2 was assisted off the floor. The doctor was notified and ordered for Resident #2 to be transferred to the emergency room for evaluation. Licensed Practical Nurse #3 stated Certified Nurse Assistant #3 left Resident #2 on the toilet to do something else. During an interview on [DATE] at 2:30 PM, Nursing Supervisor #2 stated they observed Resident #2 lying on the bathroom floor on their right side. Nursing Supervisor #2 stated they assessed Resident #2, who had a hematoma on the right side of the forehead with bleeding. Nursing Supervisor #2 stated Resident #2 was assessed to be alert with some confusion. Neuro check was at their baseline and Resident #2 had no complaints of pain or discomfort. Registered Nurse Supervisor #2 also stated the Medical Doctor was notified and ordered Resident #2 to be transferred to the hospital for a head Computed Tomography scan, bilateral hip, and pelvis x-ray. As per the Registered Nurse Supervisor #2, the fall was not witnessed, and it was uncertain as to why Certified Nurse Assistant #3 left Resident #2 alone on the toilet. During a telephone interview with the Director of Nursing on [DATE] at 1:50 PM, the Director of Nursing stated the Fall Risk Lesson Plan Policy dated ,[DATE] was developed by them after Resident #2's fall. The Director of Nursing stated staff were told not to leave residents at risk for fall in the bathroom by themselves. The Director of Nursing also stated the instruction (not to leave resident in the bathroom by themself) would be on the electronic kiosk and a green star (at risk for fall) would also be at the resident's name. The Director of Nursing further stated after Certified Nursing Assistants receive their resident assignment, they must check the kiosk for resident level of care before caring for the resident. The Director of Nursing stated after the charge nurse gives report, they also tell the Certified Nursing Assistants to check the kiosk. The Director of Nursing stated Certified Nursing Assistant #2 is from an agency and had been assigned to Resident #2's unit. The Director of Nursing stated they didn't know why Resident #2's latest Briggs assessment dated [DATE] identified Resident #2 not at High Risk for fall. The Director of Nursing stated Resident #2 sustained a hematoma to the head. 10 NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedJanuary 8, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DP(NAME) F689 1.Immediate Correction: 1) The facility respectfully states Resident # 1 expired on [DATE] while in the hospital. 2)On [DATE] CNA #1 was terminated from employment and the Agency was notified of the reason for termination. 3)On [DATE] the DNS provided LPN# one with education and counseling on the need to conduct a thorough Shift report for all staff and the need to adjust CNA assignment as needed. 4)On [DATE] Rehab assessed resident post fall and there were no changes. 5) On [DATE] the DNS provided education and counseling for CNA #2 on the need to provide residents at risk for falls and/or with impaired cognition constant supervision when seated on the toilet. 6) On [DATE] resident #2 was assessed by the Rehab Department for the need for any assistive device to use when using the toilet. CCP was updated to reflect current toileting needs and supervision required. Instructions were carried over to CNAAR. 7) On [DATE] the facility contracted with GNYHCFA to develop and implement a DP(NAME) and Directed Inservice. 8) On [DATE] the GNYHCFA QA Consultants convened the Facility QA Meeting to review causative factors, specific interventions, and systems to maintain compliance with ensuring that the environment is as free of accident hazards as possible and that each resident receives adequate supervision to prevent accidents. II. Identification of Others: 1)The facility respectfully states that all residents were potentially affected. 2) The DON /RNS will reassess all facility residents for fall risk. The RNS will review/revise Fall risk CCP and CNAAR for individualized safety interventions as indicated. 3) A list of all residents requiring substantial to maximum assistance with transfer to the toilet was generated by the MDS Coordinator from the medical record. 4)The DON, RNS and MDS Coordinator reviewed each resident to determine the supervision required when sitting on the toilet considering fall risk, cognition, and behaviors. The residents CCP will be updated and instructions carried over to CNAAR. Any identified issues will be addressed. III. Systemic Changes: 1) The DON and GNYHCFA Consultant reviewed and revised the Policy and Procedure for Fall Prevention. 2) The DON and GNYHCFA consultant reviewed and revised the Policy and Procedure for CNA Accountability /Assignments. 3) All Nursing Staff and Rehab staff will receive Education by GNYHCFA on ensuring that the environment is as free of accident hazards as possible and adequate supervision and assistance is provided to residents to ensure resident safety. Highlights of the Lesson Plan include: ?ÇóAll residents are assessed for Falls Risk on admission, readmission and quarterly and as needed. ?ÇóAny resident at High risk for Falls will be placed on the Falling Star identifier program with a green star in Electronic Medical Record (EMR), on Resident door and assistive mobility device if indicated. ?ÇóAny resident requiring physical assistance getting on/off toilet and/or with cognitive impairment cannot be left unattended in the bathroom. ?ÇóThe joint responsibility of Rehab and Nursing to determine the amount of staff assistance required for all ADL's. ?ÇóThe responsibility of the RNS to clearly communicate and document on the CNAAR/CCP the assistance needed for resident safety. ?ÇóThe responsibility of the RNS to conduct Unit Rounds to supervise direct care staff for care provided to residents. ?ÇóThe responsibility of the licensed unit nurse to complete assignments for CNAs and print from EMR a current list of residents requiring Mechanical lift with two persons and provide Shift Report to all CNAs. ?ÇóThe responsibility of each CNA to identify the transfer status of their assigned residents and the steps to take to perform task. ?ÇóThe steps the Nursing Assistant needs to take if he/she feels the directives for Residents care needs should be reviewed by the RNS/ IDT. ?ÇóThe responsibility of all Nursing Staff to be aware of each resident's need for assistance and supervision as documented in the resident's CCP/CNAAR to prevent accidents. IV. Quality Assurance: 1) The GNYHCFA Consultant in conjunction with the DON developed an audit tool to monitor the facility?ÇÖs compliance with: A) Ensuring that each resident is provided with adequate supervision and assistance to ensure Resident safety while assisting residents with toileting and transferring care needs. B) Ensuring that all residents at high risk for falls will be identified and individualized interventions will be communicated to Direct Care staff 2) Audits will be done by the RNS on five randomly selected residents, and five randomly selected staff members on each unit on random shifts weekly x 4 weeks followed by monthly x 6 months. 3)Findings from the audits that require corrective actions will immediately be rectified and brought to the Morning QA Meeting for review. 4)Findings will be reviewed during the Quarterly QA Meeting to ensure sustainability. V. Person Responsible for this FTag: Director of Nursing |