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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews completed during an abbreviated survey (NY 237), the facility did not ensure that a resident received treatment and care in accordance with their comprehensive person-centered care plan. Specifically Resident #1 had a care plan in place, that documented that they required 2 staff members to provide all care. On 7/23/2024 a single Certified Nurse Aide provided care singlehandedly to Resident # 1. The finding is: The facility policy titled Lifting and transferring a Child revised on 11/2024 documents that all lifting, and transfers are conducted by trained direct care staff and or clinical staff and or trained family members. It further documened that once the transfer designation is established in the care plan it must be followed at all times within the facility by all direct caregivers. Resident #1 originally admitted on [DATE], readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 annual minimum data set, a resident assessment and screening tool, dated 7/18/2024 indicates that Resident #1 had an absence of spoken words, they could sometimes make their needs or wants to be known, and sometimes understand others, they were wheelchair bound, the resident was dependent on others for all cares, bilaterally impaired on upper and lower extremities, and moderately impaired for decisions regarding tasks of daily living. The facility also evaluated residents with their own fracture risk assessment tool, and Resident #1 scored a 13, a score of 10 or more indicates that the resident may be at risk for significant bone fragility and may merit further evaluation. The two items that increased this resident's score are chronic immobilization and use of anticonvulsant medication [MEDICATION NAME]. The internal investigative summary revealed that on 7/24/2024 at 9:30am it was noted that Resident #1 was showing signs of discomfort after they had been transferred to their wheelchair. The resident was assessed and noted to have swelling to their left thigh, and it was noted to be larger than the right thigh. Resident was transferred to the hospital to rule out fracture. There was a statement made by Certified Nurse Aide #1 that indicated they provided care alone, they wrote in the internal investigation that they pulled the chuck up because the resident was mostly on their side, a little on their back, and this moved the resident so that they faced the wall. The investigative summary documented a review of the video surveillance. It revealed that Certified Nurse Aide #1 went into Resident #1's space, they closed the curtain, so their actions are not in view. The summary documented the statement given by Certified Nurse Aide # 1. They stated that they they were alone, and they moved the resident by themselves. Review of care plans revealed that resident #1 was identified at risk for abuse. The goal was that Resident will remain free from abuse, neglect exploitation and mistreatment this plan was last reviewed on 8/6/ 2024. Another care plan for for bed mobility was last reviewed on reviewed on 10/02/2023, it documented that there are to be 2+ person physical assist, once caregiver supporting Resident's leg and trunk and one caregiver on the side of the bed for peri care. Registered Nurse # 3 wrote a note on 7/24/2024 that documented Resident #1 was received in bed at 7:30am, vitals were taken and within normal range. Morning medications were given as ordered. Upon assessment, resident had a bowel movement and voided. Resident was not crying but upon movement of lower extremities they seemed generally uncomfortable Certified Nurse Aides to bedside to perform cares secondary to large bowel movement. Certified Nurse aides performed cares and then transferred resident to their chair. Physical therapist went to Registered Nurse #3 secondary to suspected continued discomfort medical provider informed, Resident #1 noted with possible left leg swelling. Resident #1 transferred back to bed and measurements were made of legs, confirming left thigh larger than right. Resident #1 to be transferred to hospital for full assessment and mother made aware. The disciplinary Action form for Certified Nurse Aide #1 documented that during an investigational camera review/look back for a fracture on a Resident #1, Certified Nurse Aide #1 was noted as having repositioned the resident using a chuck without a second person this occurred and could be seen on video surveillance on 7/23/ 2024. Resident #1 is ordered for 2-person transfer/ADL/bed mobility. The corrective action was that the Certified Nurse Aide #1 will provide ALL care to ALL residents according to the care plan. Any future violation will result in termination. Certified Nurse Aide #1 was suspended for 5 days as a result of their action. During an interview on 3/4/25 at 12:50pm Registered Nurse #3, stated that they were s a care provider for Resident #1 at least 3xs a week. In the interview Registered Nurse #3 stated that the resident was a 2-person transfer- 2 person ADL care. 2 people always provided care. 10NYCRR 415. 12 | Plan of Correction: ApprovedApril 8, 2025 I Corrective Action: 1. Staff CNA #1 suspended for five days. 2. CNA #1 re-educated on reviewing Nursing Instructions through the EMR system prior to providing ADL care. II. Potential of other Residents to be affected: 1. Video of the residents on the CNAs assignment were reviewed and no other residents were affected. 2. Since (MONTH) 24, 2024, 369 videos of were reviewed to ensure compliance with care plans. 3. All direct care staff are to be re-educated on the Personal Hygiene Policy, which was revised to include verifying Nursing Instructions via the EMR system. III. Measures and Systemic Changes: 1. Revised Personal Hygiene Policy on 3-25-25 to include CNAs verifying Nursing Instructions via the CNA kiosk (Nursing Instructions replicate resident ADL support needs as outlined in the Care Plan) 2. Re-educate all direct care staff by (MONTH) 30th, 2025. IV. Monitoring Corrective Actions: 1. Personal Hygiene Policy education will be reported to the Quality and Safety Committee upon completion. 2. 30 in person ADL observations will be conducted monthly by Nurse Managers/Supervisors for 60 days. Any non-compliance will be addressed immediately. 3. Completion of the Plan of Corection will be reported to the Quality and Safety Committee. V. Date of Correction and Title of Person responsible for correction of deficiency: Corrective Action Completion dateÔÇ£ 5-9-2025 The Director of Nursing is responsible for the corrective action. |