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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, conducted during an abbreviated survey (NY 382 and NY 103), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 3 residents (Resident #1 and #3) reviewed. Specifically, on 9/3/2024 Resident reported they were bumped by the elevator door whiles exiting and reported pain 3 out of 10 to their right hip. 2) On 9/30/2024 while exiting the core elevator on the 4th floor, the elevator door closed hitting Resident #1's right hip causing pain and discomfort. 2) On 11/25/2024, Resident #3 was found inside of the facility housekeeping closet on the 4th floor. Facility investigation revealed the housekeeping door was unsecure due to the striker plate being broken. Resident #3 who had a history of [REDACTED]. Findings include: The facility's policy on Accidents and Supervision dated 6/17/2021 documented the resident's environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents. The purpose of this policy is to prevent injury to the resident. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 1/2/2025, documented the resident had a Brief Interview for Mental Status assessment (BIMS, used to determine attention, orientation, and ability to recall information) score of 7/15, associated with severe cognitive impairment. Resident #1 was independent with bed mobility and with walking with a rollator/walker and required occasional supervision or touching assistance with transfers, bathing and dressing. Review of Resident #1's Care Plan dated 9/5/2024 documented interventions that included monitor and report pain. Review of the Nurse's Progress note written by Licensed Practical Nurse #3 on 9/5/2024 at 1:53pm documented that at approximately 12:00pm, Resident #1 complained of a pain in their right hip area, which they felt during ambulation. Upon interviewing Resident #1, they stated that the pain was a result of an incident that occurred on 9/3/2024 during the day shift, where the elevator closed into their right hip. Resident #1 has a history of hip replacement in that hip. Review of the Nurse Practitioner Progress Notes written by Nurse Practitioner#1 on 9/5/2024 documented trauma to right hip. Residents #1 reported worsening pain to right hip with trauma from elevator. Resident #1 also reported having hip surgery on the right hip in the past and denied any fall during the elevator incident. No external rotation noted or difference with the length to the right leg. Reported slight discomfort rated 3/10, full range of motion without issues, ambulating well. an order for [REDACTED]. Review of the X-ray results dated 9/16/2024 revealed no radiographic evidence of acute fracture or dislocation. Review of the Accident/ Incident Report dated 9/5/2024, documented that Resident #1 reported to Licensed Practical Nurse #3 that they were feeling pain of 3/10, to the right hip. Resident #1 stated that they had gotten bumped by the elevator door earlier. No bruising was present. Nursing will monitor and medicate Resident #1 for pain. No evidence of abuse, mistreatment, or neglect. The facility plans to prevent reoccurrence included to remind Resident #1 to report any discomfort to nursing staff. Review of the Accident/Incident Report dated 9/30/2024 documented Resident #1 reported to Licensed Practical Nurse #2 they were attempting to exit the elevator and was bumped by the door on the right hip. Resident #1 has a history of pain to this area and multiple hip replacements. Plan was for elevator sensors to be cleaned, and this was completed on 9/30/ 2024. Review of the Nurse's Progress note written by Licensed Practical Nurse #2 on 9/30/2024 at 3:20pm, documented that Resident #1 reported to Licensed Practical Nurse #2 that they were riding the core elevator with a large group of people. When the resident needed to exit on the fourth floor, the group of people exited the elevator and Resident #1 was the last to exit. As they exited, the elevator door bumped on their right hip. Resident #1 complained of mild discomfort. All elevator sensors were cleansed by housekeeping. Review of Resident #1's Care Plan dated 9/30/2024 revealed interventions that included an order for [REDACTED]. During an interview conducted on 1/14/2025 at 2:05pm, the Social Services Director stated Resident #1's cognition had declined in the last couple of years. Resident #1 is now using the rollator all around the building. Resident #1 visits other residents and goes to activities. Resident #1 uses the elevator by the coffee shop and does not have a wander guard. The Social Services Director stated they were not aware of the elevator incident that happened September 2024. During an interview conducted on 1/14/2025 at 2:37PM, Resident #1 stated I think my room number is forty something. I have been living here for more than [AGE] years and I have never had to look at the number of my room, I just know where to come back to. Resident #1 stated they walk around the building with their walker and when asked which elevator they used, Resident #1 stated the elevator to the left (pointing to the unit 4B elevator). Resident #1 reported that they had pain to the right hip, and it came from the elevator doors hitting them one of the days when they were exiting the elevator When asked if the elevator doors had closed on them recently, Resident #1 responded no it hasn't happened again, and I am happy with the care I receive from the staff. During an interview with the Director of Support Services was conducted on 1/17/2025 at 3:42pm they stated they were not aware of the two elevator incidents that occurred in (MONTH) 2024 involving Resident # 1. They were only notified of these elevator incidents yesterday (1/16/2025). If they were aware of an issue with an elevator, the process would be to key out or lock the elevator to prevent access and call the company that does repairs and maintenance, so they can come out and fix the problem. This will be documented on the facility service log. The Director of Support Services stated they did not know why they were not informed of these incidents with the elevator. During an interview conducted on 1/17/2025 at 4:26pm, the Director of Nursing was asked why the Director of Support Services was only notified yesterday (1/16/2025) of the elevator incidents that occurred on 9/3/2024 and 9/30/ 2024. The Director of Nursing stated they were not sure how the incident was not reported to the Director of Support Services. During a follow up telephone interview with the Director of Nursing conducted on 1/22/2025 at 12:15pm they stated the Director of Support Services oversees the Maintenance, Housekeeping and Engineering Departments. When asked if Director of Support Services was the staff that would have been notified of the elevator incidents that happened in (MONTH) 2024, the Director of Nursing stated yes, they would be the person to be notified. 2)Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated 11/13/2024, documented a Brief Interview for Mental Status assessment (BIMS, used to determine attention, orientation, and ability to recall information) score of 3/15, associated with severe cognitive impairment. Noted with behaviors present. A review of the discharge Minimum Data Set assessment dated [DATE], documented the resident was dependent with toileting, bathing and dressing and requ | Plan of Correction: ApprovedFebruary 11, 2025 F689: Free of Accidents, Hazards, Supervision, Devices I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 had a pain assessment completed on 1/31/25 which indicated he did not have any pain. Resident #1 receives a pain screen completed every shift and has PRN APAP ordered that can be administered if needed. Resident #3 is non-ambulatory, requires extensive assistance from staff for ADL care/mobility (since last readmission on 12/17/24), and is no longer an elopement risk. His elopement assessment was updated on 1/31/25, along with his comprehensive care plan to reflect the changes in his medical status and low elopement risk. II. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. Specific to resident #1, a work call was placed to Otis to have the elevator sensors inspected and cleaned, which was completed on 1/15/ 2025. House-wide education is in progress for all staff on reporting accidents and incidents through the appropriate chain of command, ensuring notification is made to the highest-level supervisor in the facility. Nursing Supervisors have been re-educated to immediately notify the Director of Support Services, or designee, via phone and email if an accident/incident occurs involving equipment that is not maintained by nursing. Specific to resident #3, all locked housekeeping closet doors have been checked, with no other striker plates found to be loose or otherwise malfunctioning, which could lead to recurrence. III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Routine maintenance/cleaning of the elevator sensors have been added to the Otis monthly preventative maintenance schedule. Incident and Accident Reports (I&As) are discussed the business day following the occurrence during the Interdisciplinary Team (IDT) morning meeting/clinical meeting. This ensures that follow-up has been communicated and completed. The Director of Nursing Services will complete an audit weekly for 12 weeks of all I&As to ensure no follow-up is omitted or missed during the IDT's review. Results will be presented to the QAPI committee monthly. The Director of Support Services, or designee will conduct audits twice daily to ensure locked housekeeping closets are secure and no other striker plates were loose, malfunctioning, or presented danger to residents. These audits will be completed for a period of at least 90 days post incident, seven days a week. Results will be presented to the QAPI committee monthly. Education is in progress with all nursing staff on Incident & Accident notification process for significant occurrences. This training will also be included in new care member orientation for all new staff. IV. How will corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of the locked housekeeping door audit and the I&A audit are given to the Director of Support Services and Director of Nursing Services, respectively, for review, and are also presented to the QAPI committee monthly. The QAPI committee will determine when substantial compliance has been achieved, and when the audits can be discontinued, frequency changed, or if they should continue as currently scheduled. V. The date for correction and the title of the person responsible for correction of each deficiency? Date Certain - 3/17/2025 Person Responsible - Director of Support Services |