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Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 16, 2025
Corrected date: March 16, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the post-survey revisit and abbreviated surveys (NY 558, NY 382, and NY 722), the facility failed to ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated and failed to ensure prevention of further potential neglect or mistreatment for 1 of 4 residents (Residents #7) reviewed. Specifically, Resident #7 was lowered to the floor by staff and was assisted off the floor without an assessment by a qualified professional. The staff involved did not report the incident immediately to Administration and an investigation was not immediately initiated to rule out abuse/neglect. In addition, when the facility completed the investigation, there was no documented evidence they identified the delay in reporting the incident to Administration and no documented evidence the involved staff were re-educated on timely reporting of incidents. Findings include: The facility policy Abuse revised 2/2019 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The shift Supervisor/Charge Nurse was identified as responsible for immediate initiation of the reporting process upon receipt of the allegation. The Administrator and Director of Nursing (DON) were responsible for investigation and reporting and the investigation should be thorough with witness statements from staff, residents, visitors, and family members who may have information regarding the allegation. The facility policy Accident-Incident, revised 7/2020, documented an incident was any occurrence not consistent with routine operations. The occurrence could be a fall and may involve abuse, neglect, and mistreatment or an injury of unknown origin. The process for reporting an incident or accident included: - The nursing Supervisor/Charge Nurse, Unit Manager, and or department Director or Supervisor should be promptly notified and then was responsible for assessing, reviewing, documenting, and reporting of the incident or accident. - Regardless of how minor an accident or incident involving a resident, staff must report the occurrence to the Nurse Manager or nursing Supervisor as soon as practical. The Supervisor must be informed of all accidents or incident so that medical attention can be provided. - The resident will not be moved until they have been examined by a licensed profession for possible injuries. - Notification of the Medical Director or the resident's personal or attending physician to inform them of the accident or incident was to occur. - Licensed staff should initiate incident reporting and complete by the end of their shift. The facility policy Falls Management and Prevention, revised 1/2021 documented: - the distinct definition of a fall for all CMS (Centers for Medicare and Medicaid Services) participants including this facility was defined as the unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g. onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident was found on the floor or ground. - An intercepted fall occurred when the resident would have fallen if they had not caught themselves or had not been intercepted by another person and this was still considered a fall. Resident #7 had [DIAGNOSES REDACTED]. The 6/1/22 Minimum Data Set (MDS) assessment documented the resident was admitted from the hospital. There were no additional MDS assessments completed after 6/1/ 22. The baseline comprehensive care plan (CCP), initiated by registered nurse (RN) #11 on 6/1/22 documented the resident was able to communicate easily with staff; was alert and cognitively intact; had a goal for rehabilitation and then to return home; needed 1 person physical assistance for personal hygiene, use of the toilet, and bed mobility, and needed 2 plus person assistance for transfers with a Hoyer lift (mechanical lift). On 6/14/22 at 8:46 AM, the resident was interviewed and stated one day they slipped out of their wheelchair because they could not stand as they normally did. They stated they were not feeling strong that day and could not get from the bed to the wheelchair and they slid about 6 inches from the wheelchair to the floor. The resident stated they were admitted to the facility to get stronger because they were in a coma from COVID- 19. They stated they hoped to get their muscle tone back in their arms and legs. Physical therapist (PT) #12's progress note on 6/2/22 documented the resident's goal was to return home. The resident was fearful to trial stand and stand pivot but was willing. The resident was able to stand from the edge of the bed to a 2 wheeled walker with moderate assistance and verbal curing. The resident was notably fatigued following the transfer and would benefit from skilled PT services. The care instructions dated 6/3/22 documented the resident transferred with extensive assistance of one person (staff physically lift, bear, hold or support any amount of weight at any time). The 6/4/22 at 5:00 AM licensed practical nurse (LPN) #13's progress note (entered as a late entry for 6/3/22 at 3:30 PM) documented the resident requested to go to the bathroom and certified nurse aides (CNA) attempted to walk the resident but found they were too weak. The CNAs then attempted to use the sit to stand lift and reported to LPN #13 the resident was too weak. LPN #13 went to the room and found the resident could not hold their arms down so the sit to stand lift could not be used. LPN #13 instructed the staff to lower the resident to the floor and then transfer the resident off the floor with a Hoyer lift. The resident was transferred from the floor to the bed with a Hoyer lift. The resident had no complaints and at no time were they dropped or in danger of being hurt. The 6/4/22 at 2:00 PM, RN #11's progress note documented the resident had a fall and per the physical therapy assistant (PTA), the resident stated they fell out of their wheelchair onto the floor during the evening of 6/3/ 22. The resident denied pain or injury. Full range of motion (ROM) was noted to all extremities and the Director of Nursing (DON) was aware of the incident. The facility's investigation documented: - on 6/4/22 at 2 PM, nursing became aware of a fall after the resident reported it to PTA # 16. - PTA #16's statement dated 6/4/22 documented on that date, the resident reported that on 6/3/22 they were having difficulty standing. The CNA left the room to get help and when they returned, the CNA turned the chair around quickly and the resident fell from the chair to the floor. - The DON documented on 6/4/22 they interviewed the resident who confirmed on 6/3/22, they fell on their bottom but didn't get hurt. - The DON completed an IDT (interdisciplinary team) to Rehabilitation Referral Form on 6/4/22 and documented the resident was lowered to the floor while in the sit to stand lift and the sling slid up the axillary (underarm) area. The request was for therapy to evaluate transfer status. - The DON documented phone interviews with LPN #13 and CNAs #1 and 14. The interviews documented the resident was too weak to transfer with CNA assistance or the sit to stand lift and was either lowered to the floor by staff or sat themself on the floor. None of the interviews documented the resident was assessed by a qualified professional prior to transfer off the floor. The interviews documented LPN #13 watched the event from the doorway. None of the interviews mentioned an incident report being initiated on the date of the incident. - An email from LPN #15 dated 6/4/22, sent to the DON documented it was LPN #15's account of the incident on 6/3/ 22. LPN #15's statement documented being aware the resident sat on the floor during a transfer and made no mention of an assessment of the resident being completed when the resident was on the floor or of an incident report being initiated on the date of the incident. There was no documented evidence CNAs #1 and 14 and LPNs #13 and 15 were re-educated on reporting incidents timely, initiating incident reports, and/or ensuring residents were assessed by qualified professionals following falls. During an interview on 6/16/22 at 9:15 AM, PTA #16 stated on 6/4/22, the resident reported to them that they fell from their wheelchair on 6/3/ 22. PTA #16 reported it to their supervisor and was asked to write a statement which they did. During an interview on 6/16/22 at 9:32 AM, the DON stated on 6/4/22, the resident told PTA #16 that they fell on the evening of 6/3/ 22. PTA #16 notified their supervisor who then notified the DON. The DON came to the facility on [DATE] and the resident reported to the DON they slid to the floor on 6/3/ 22. The DON stated they completed an assessment of the resident with no findings on 6/4/ 22. The DON stated they identified a need for re-education and provided CNA #1 with education on professionalism and referring to the resident care instructions. During a telephone interview on 6/16/22 at 12:29 PM, CNA #1 stated on 6/3/22, the resident rang the call bell and they responded. The resident was in the wheelchair and needed to be toileted. CNA #1 stated they tried to get the resident up and was not able to, so they got CNA #14 to help. CNAs #1 and 14 could not get the resident to stand so they tried the sit to stand lift which the resident was not able to use. During the transfer, the resident sat on the floor. LPN #13 was standing in the doorway monitoring care and had them Hoyer lift the resident from the floor to the bed. CNA #1 stated if a resident went from a chair to the floor, it was a fall, but an incident report was not completed at the time of the incident as the staff did not think it was a fall. LPN #13 was monitoring the CNAs, and nurses were supposed to start incident reports. During a telephone interview on 6/16/22 at 1:29 PM, CNA #14 stated CNA #1 asked for help transferring the resident on 6/3/ 22. They could not transfer the resident, so they tried a sit to stand lift and the resident was not able to use it. The resident sat on the floor in the middle of the transfer. LPN #13 was watching CNAs #1 and 13 from the doorway and had them Hoyer lift the resident from the floor to the bed. CNA #14 stated the incident was not considered a fall because the resident sat on the floor. CNA #14 stated a fall was an uncontrollable touching of the floor. CNA #14 stated incident reports were completed by the nurses. During a telephone interview on 6/16/22 at 1:53 PM, LPN #13 stated on 6/3/22, the resident asked to go to the bathroom and the CNAs (CNAs #1 and 14) were not able to stand the resident up. They tried the sit to stand lift and were not able to transfer the resident with the lift as the resident was too weak. LPN #13 stated they told CNAs #1 and 14 to lower the resident to the floor and they moved the resident from the floor to the bed with a Hoyer lift. LPN #13 stated they were in an out of the room as this was occurring. LPN #13 stated they did not think lowering someone to the floor was a fall as they thought they were preventing a fall. Before the CNAs Hoyer lifted the resident from the floor to the bed, they checked the resident's range of motion as there was no Supervisor in the building. LPN #13 stated they would not call a medical provider or the DON when a resident was on the floor unless they thought the resident was hurt. During an interview with the DON on 6/16/22 at 2:15 PM, they stated the resident sitting on the floor was considered a fall. The DON stated when they interviewed the staff on 6/4/22 they stated the resident did not fall but sat on the floor. The DON explained to them sitting on the floor was considered a fall. The DON stated LPN #13 was in the room and evaluated the resident when they were on the floor. The DON stated it was not facility policy for staff to call the DON when the resident was on the floor if there was no RN In the building. The DON stated the resident went a shift without a RN assessment following the fall and the DON assessed the resident on 6/4/ 22. The DON stated informal staff education was done after this incident. LPN #13 should have completed an incident report on 6/3/22 as the resident had a fall. 10NYCRR 415. 4(b)(2,3) | Plan of Correction: ApprovedFebruary 11, 2025 1. For resident #4 specifically facility has added an order to document when the resident refuses to get out of bed for meals. Resident #4 also worked with SLP upon returning to the facility from choking incident dietary order was changed (MONTH) 21, 2024 to reflect speech language pathologist recommendation. 2. All personnel involved in serving residents have been educated on the different consistencies in the facility completed on (MONTH) 24, 2024. 3. Diet tech and dietician will interchangeably complete weekly meal audits. Findings will be presented to the quality assurance team. Any immediate findings will be corrected accordingly. Date: 3/16/2025 4. Speech Language Pathologist will review all menus and extensions to ensure that we are serving appropriate foods for all consistencies. Date: ongoing 5. The speech language pathologist initiated review of all residents in alignment with the MDS schedule starting (MONTH) 2024 and has continued to do. Completed: (MONTH) 2024 Responsible party: speech language pathologist 6. SLP will communicate any dietary changes to the clinical team utilizing communication log and the dietary team via email, nursing will be responsible to make change in EHR and diet tech will reprint the dietary roster. 7. Findings from all audits will be presented to the Quality assurance team monthly for 3 months then quarterly. Responsible party: dietary |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 16, 2025
Corrected date: March 16, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated Survey (NY 559) for one (1) (Resident #4) of three (3) residents reviewed, the facility did not ensure food was prepared in a form designed to meet the residents needs as recommended by the speech-language pathologist and physician's orders [REDACTED].#4 had a [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #4 that was not Immediate Jeopardy as evidenced by the following: The facility policy Aspiration Precautions Protocol, dated (MONTH) 2023, documented that a resident's meal tray should be checked with the meal tray ticket or card for accuracy. Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 05/29/2024, documented the resident had moderately impaired cognition and was on a mechanically altered diet (food is chopped, ground, or pureed to make it easier to swallow) and required set-up assistance for meals. Review of the Speech Language Pathology evaluation, dated 03/13/2024, revealed Resident #4 required a ground/soft diet with thin liquids. Review of physician's orders [REDACTED].#4 was on a ground/soft diet. In a nursing progress note, dated 07/16/2024 at 8:33 PM, Registered Nurse #1 documented Resident #4 had their call light on at approximately 6:50 PM to 7:00 PM and when they entered the room Resident #4 whispered to them that they were choking and could not breathe. Registered Nurse #1 raised the resident's head of the bed to a 90-degree angle, administered back blows and the [MEDICATION NAME] maneuver (a first aide procedure for choking) and the resident's mouth was suctioned for mucous only. Registered Nurse #1 called 911 and the on-call medical provider, and the resident was transferred to the hospital. In a nursing progress note, dated 07/16/2024 at 9:12 PM, Registered Nurse #1 documented that Resident #4's tray table had contained three cups of beverages, but their dinner tray had been removed prior to them entering Resident #4's room. In an emergency room medical progress note, dated 07/16/2024 at 7:59 PM, the physician documented that Resident #4 was admitted to the emergency room in acute respiratory distress, unable to speak and had [DIAGNOSES REDACTED]. In an emergency room medical progress note, dated 07/16/2024 at 9:14 PM, the respiratory therapist documented Resident #4 was given medication for conscious sedation (a form of sedation that helps a patient to relax during a medical procedure) and two large pieces of chicken approximately four centimeters in size were removed from Resident #4's airway with forceps (medical device resembling a pair of tongs). In an interdisciplinary team progress note, dated 07/17/2024 at 12:26 PM, Nurse Practitioner #1 documented Resident #4 was found on 07/16/2024 choking on dinner and was transferred to the hospital in acute respiratory distress for presumed airway obstruction, was hypoxic (lack of oxygen) on six liters of oxygen and an airway obstruction extraction (removal) under sedation was performed using forceps. A post procedure chest x-ray was significant for bilateral atelectasis (collapsed lung on both sides). The resident had stated they choked immediately upon eating chicken for dinner that night. In an interview on 12/31/2024 at 4:12 PM, the Administrator stated if a resident choked (while eating), an investigation should be done and should include a determination that the correct food consistency had been served. After reviewing the incident report for Resident #4's choking incident, it appeared there was no food found in the room, the resident was alone, and they were unsure of how to determine if the correct consistency had been provided to the resident. The staff member who served the tray was no longer at the facility. The Administrator stated staff should confirm food consistency with the meal ticket before serving the meal. During interviews on 01/02/2025 at 10:04 AM and again at 4:55 PM, Director of Nursing #2 stated they were not the Director of Nursing at the facility when the incident occurred. Director of Nursing #2 stated that in the event of a choking incident, details about what food consistency was provided to the resident should be investigated to ensure that dietary orders had been followed for the safety of the resident. During an interview on 01/16/2025 at 9:37 AM, Nurse Practitioner #1 stated giving the incorrect consistency diet could potentially result in problems with chewing and swallowing, and lead to aspiration (inhalation of food into the lungs). Nurse Practitioner #1 stated it would be important to determine if the correct food consistency was given to Resident #4, but the information they had received was that the resident's tray was taken away prior to their choking incident. During an interview on 01/16/2025 at 10:18 AM, the Speech Language Pathologist stated a four-centimeter piece of meat would not be considered safe on a ground/soft diet. 10 NYCRR 415. 14(d)(3) | Plan of Correction: ApprovedFebruary 12, 2025 1. The Director of Nursing and Administrator have reviewed the incident and accident policy. The policy has been revised to rule out neglect, abuse and mistreatment within 72 hours of incident. Completed: 1/31/2025 2. All clinical staff will be educated on the incident and accident policy. Date: 2/28/2025 2. The lead investigator will interview all staff whom worked to determine if abuse, neglect, or mistreatment is involved. if determined with 72 hours the staff will be suspended pending investigation. 3. Review of aspiration protocol was completed by the Administrator, Director of Nursing and Medical Director, and speech pathologist. Reeducation will be held with existing clinical staff on facility aspiration protocol. Completion date: 2/28/2025 4. For resident #4 specifically facility has added an order to document when the resident refuses to get out of bed for meals. Resident #4 also worked with SLP upon returning to the facility from choking incident dietary order was changed (MONTH) 21, 2024 to reflect speech language pathologist recommendation. Completed: 8/21/2024 5. Aspiration precautions residents will receive tray when C.N.A and/or licensed clinical staff are able to visualize consumption of meal. If the tray or meal ticket are incorrect tray will be withheld until staff notify the kitchen immediately for correction and inform supervisor of the error. Completion date: on-going 6. Findings will be reported to the Quality assurance team on a monthly basis for 3 months then quarterly. Responsible party: Director of Nursing |