NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: February 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #'s NY 986, NY 919, NY 950, and NY 114), the facility failed to ensure the residents' right to be free from abuse and neglect for four (4) (Resident #'s 1, 2, 3, and 4) of four (4) residents reviewed for abuse and neglect, which included physical, verbal and mental abuse. Specifically, ( 1. ) Video footage documented Resident #1 was pushed to the floor on 2/02/2025 at 5:03 PM by Shahbaz (Certified Nurse Aide) #1, transferred off the floor by Licensed Practical Nurse #1 without an assessment by a Registered Nurse, and suffered a broken hip. ( 2. ) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/ 2024. Resident #2 attempted to get themselves off the toilet and subsequently fell and suffered an injury to their right shoulder. ( 3. ) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F*** down. ( 4. ) On 11/08/2024 at 3:00 AM, Resident #4 used their call bell requesting assistance, Shahbaz #6 entered the room and pushed the resident down on the pillow. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety and had the potential to affect all 177 residents in the facility. The immediate Jeopardy was lifted on 2/13/ 2025. This is evidenced by: Cross-referenced to: F609: Reporting, F610: Investigate/Prevent/Correct Alleged Violations. Review of the facility Abuse Prevention & Investigation Policy, dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above. - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and Trinity Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident had severely impaired cognition and could usually be understood and could usually understand others. Review of video surveillance footage on 02/11/2025 at 4:00 PM revealed that on 02/02/2025 at 5:00 PM: 1. Shahbaz #1 was with Resident #1 in the hallway. 2. Resident #1 was ambulating with their hands behind their back, without the need of an assistive device. Resident #1 walked over to the dining table and was stopped by Shahbaz #1, who blocked the resident from going to the table, pushing the resident in a backward motion. 3. Shahbaz #1 grabbed Resident #1 by the arm. Resident resisted, and Shahbaz #1 placed their hands on the resident's arms, spun the resident by pulling them around, and pushed the resident backward while the resident was trying to prevent the Shahbaz from grabbing them. 4. Once Resident #1 was up against the wall in a backward position, the resident attempted to steady themselves by grabbing for the handrail but was unable to hold on to the rail. 5. Shahbaz #1 let go of Resident #1 with a push, and the resident began to fall to the ground. 6. Shahbaz #1 made no attempts to stop or break the resident's fall. 7. Resident #1 fell against the wall; resident's legs appeared to buckle or twist. The resident reached for the handrail again but could not hold on to it and fell on their right hip. 8. Shahbaz #1 looked at Resident #1, who had fallen, and walked away from the resident. Resident #1 was then alone on the floor as Shabazz #1 transported other residents to the dining table. 9. Resident #1 was transferred off the floor by Licensed Practical Nurse #1, Shahbaz #1 and Shahbaz #3 without the use of a mechanical lift. Record review of an undated facility document titled Termination revealed the following: on 02/03/2025, the facility investigated a resident fall that resulted in a fracture (bone break) and hospitalization . The investigation produced credible evidence to support Shahbaz #1 physically abused and neglected the resident. Camera review showed Shahbaz #1 held Resident #1's hands while they proceeded to move them away from the table by pushing and pulling them across the hallway towards the handrail, approximately 10-15 feet. Shahbaz #1 pushed Resident #1 against the wall, their body leaning, and their gait unsteady, then they let go of the resident's hands, causing the resident to fall backwards. The undated facility document noted that based on the video footage, it was uncertain whether the resident was pushed; Shahbaz #1 proceeded to walk away from Resident #1 and left them on the floor until the nurse responded to evaluate Resident # 1. The document noted Shahbaz #1 was terminated, and the document was signed by Guide #1 (Guides oversee the Shahbaz in the homes) and Assistant Director of Nursing #1 with no date or time. Termination of Shahbaz #1 was documented as being done verbally by telephone. Nursing progress note dated 02/02/2025 at 6:13 PM, completed by Registered Nurse #1, documented that Registered Nurse #1 was called to House 16 for a witnessed fall. It documented the following: Shahbaz #1 reported that they were taking Resident #1 to their room when Resident #1 let go of the side rail and fell to the floor. Upon arrival, Resident #1 was observed sitting on the floor in the dining room. On assessment, Resident #1 was observed to be in pain with some guarding to their right thigh and was unable to stand. Resident #1 was assisted off the floor with a mechanical lift and two-person assist, then placed in a wheelchair. Physician was made aware and ordered an x-ray of the right hip, pelvis and femur. Mobile imaging was called to be in. Resident #1's family was notified and came in to visit. Vital Signs: Temperature 97. 8, Pulse 83, Respirations 20 per minute, Blood Pressure 160/ 84. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a [MEDICAL CONDITION] femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). During an interview on 02/11/2025 at 9:01 AM, Assistant Director of Nursing #1 stated Resident #1 had a fall with an injury on 02/02/2025, and video of the incident was reviewed with Guide #1 on 02/03/2025 at 10:50 AM, when abuse was discovered. They stated that Shahbaz #1 was interviewed by telephone and suspended when their recounting of the events that occurred did not match the actual events documented in the video recorded on 02/02/2025 at 5:00 PM. Assistant Director of Nursing #1 stated they then reported it to New York State Department of Health. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, to report that Resident #1 had fallen, had a fracture (bone break), and was being transferred to the hospital. Assistant Director of Nursing #1 stated they were aware Shahbaz #1 had completed their shift and left for the day, and Guide #1 confirmed with them via text message on 02/02/2025 that Shahbaz #1 was not scheduled to work on 02/03/2025 (the next day). Assistant Director of Nursing #1 stated that they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator | Plan of Correction: ApprovedMarch 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 Eddy Village Green contracted with a consultant to develop a Directed plan of correction for the issues identified by the New York State Department of Health in addition the consultant met with the Quality Assurance Committee on (MONTH) 19, 2025 to identify potential root cause issues. ELEMENT 1 Resident 1 was provided with medical intervention at time of incident. Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed to determine if any changes to routine or patterns none identified. The resident will continue to be monitored by social work to ensure no ongoing psychosocial impact from this event such as withdrawal, decreased appetite sleep disturbance. All staff involved in the cited case are no longer employed at the facility. Resident 2 Resident discharged on ,[DATE]/ 25. All staff involved in the cited case are no longer employed at the facility. Resident 3 Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented none identified. The resident will continue to be monitored by social work to ensure no ongoing psychosocial impact from this event such as withdrawal, decreased appetite sleep disturbance. All staff involved in the cited case are no longer employed at the facility. Resident 4 Resident 4 was interviewed on 3/20/25 to determine if they feel safe in the facility. Resident stated she does. Resident will be monitored and observed for any signs of psychosocial stressors related to this incident. All staff involved in the cited cases are no longer employed at the facility. Element 2 All residents have the potential to be affected by stated deficiency. All residents that reside in the facility will be interviewed by social work or designee to determine if they feel safe in the facility. Any concerns will be investigated and reported as required under New York State Department of Health reporting requirements. Interviews will be completed by (MONTH) 7, 2025. For any resident who is unable to be interviewed the responsible party will be contacted to determine any concerns. These contacts will be completed by (MONTH) 7, 2025. The past 30 days of incident reports will be reviewed by the Director of nursing or designee to determine thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrences Review will be completed by (MONTH) 30,2025 All staff were educated on abuse prevention and reporting on 2/12/2025-2/13/2025 as part of New York State Department of Health Complaint Survey. Additionally, directed inservicing is being conducted on 3/26/2025 for all staff covering investigations, prevention and reporting of alleged violations. Staff are educated on hire, annually and if an event occurs at the facility of the resident's rights to be free from abuse neglect or mistreatment. Criminal background checks as well as other registry/refence checks are completed as part of the preemployment process. Any concerns of alleged abuse the employee is suspended pending investigation and termination should allegation be substantiated. Element 3 The abuse reporting/investigation policy was reviewed by the administrator, Director of nursing, and nursing administration. The policy was revised. Policy updated to state all staff have responsibility to immediately report any abuse/allegation of neglect, mistreatment or misappropriation. Policy also updated to clarify need to report all allegations within 2 hours to New York State Department of Health and as appropriate other regulatory entities. The facility will take the following measures to ensure that the problem does not reoccur: Staff educator will educate facility staff to include housekeeping, maintenance, activities, social work, dietary, nursing and therapy on the reporting of alleged abuse violations and the requirement of reporting within 2 hours all alleged abuse. This education will also be done with on boarding of new staff and annually. Education will include but not be limited to the following: * Review of abuse reporting and investigation policy * Elder Justice Act *All allegations of abuse need to be reported immediately to the supervisor, administrator, and director of nursing for prompt reporting to New York State Department of Health *Supervisors will be educated to the online abuse reporting system to ensure timely submission of any alleged abuse, neglect, or misappropriation. The New York State abuse reporting manual, although no longer in use will be used to help outline concepts that are beneficial to the identification of potential abuse. * Resident right to be free from abuse, neglect and mistreatment * Appropriate staff treatment of [REDACTED]. * Signs of staff burnout * How to deal with residents who have escalating behaviors during care *Zero tolerance policy for abuse neglect or mistreatment shared with all staff on hire and annually Element 4 The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Audits will be completed on 5 elders and 5 staff per week. Elders will be asked if they feel safe and if they have any concerns regarding staff or care. Audits will be completed by social work or designee. Staff will be audited on his/her knowledge of abuse reporting requirements. Staff audits will be done by Nurse Manager or designee on varying shifts. Any areas identified that require follow-up or education will be done immediately. Audits to be completed weekly for the first three months. Audits will be brought to the Quality Assurance Committe monthly. Committee will make recommendations based on audit results. Administrator or designee will update and maintain Investigation Log at the time of each event to ensure that facility appropriately respond and reports allegations of abuse, neglect or mistreatment. Log will document elements including but not limited to the following: 1 Date incident reported 2. Resident demographics 3. type of event 4. If reportable reported within time frame 5. Conclusion 6. If any deficient practice identified remediation/education provided Log will be audited by Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and reeducation provided. Audits will continue weekly for three months. Log will be brought to Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy or education based on results of audits. Committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance Audits will be completed weekly for three months. Audit results will be brought to the monthly Quality Assurance Committee. Committee will be responsible to determine need and frequency of ongoing audits. Committee will make recommendations as needed based on results of audits for changes in plan, policy, or education. Director of Nursing responsible for ongoing compliance |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: February 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY 986, NY 919, NY 950, and NY 114), the facility failed to ensure all allegations of abuse were thoroughly investigated for three (3) (Resident #'s 1, 2, and 3) of four (4) residents reviewed for abuse investigation. Specifically, ( 1. ) video surveillance footage revealed Shahbaz (Certified Nurse Aide) #1 pushed Resident #1 to the floor on 2/02/2025 at 5:03 PM. There was no documented evidence the facility initiated an investigation on 2/02/2025 ( 2. ) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/ 2024. Resident #2 attempted to get themselves off of the toilet and subsequently fell and suffered an injury to their right shoulder. ( 3. ) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F*** down. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety with the likelihood to affect all 177 residents in the facility. The immediate Jeopardy was lifted on 2/13/ 2025. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F609: Reporting. Review of the facility Abuse Prevention & Investigation Policy, dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above). - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and Trinity Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident was cognitively impaired, could be understood, and understand others. Video surveillance footage revealed that on 2/02/2025 at 5:00 PM, Shahbaz #1 pushed Resident #1 and walked away. Resident #1 fell and sustained a fractured (broken) hip. Nursing progress note dated 02/02/2025 at 6:13 PM, completed by Registered Nurse #1, documented that Registered Nurse #1 was called to House 16 for a witnessed fall. It documented the following: Shahbaz #1 reported that they were taking Resident #1 to their room when Resident #1 let go of the side rail and fell to the floor. Upon arrival, Resident #1 was observed sitting on the floor in the dining room. On assessment, Resident #1 was observed to be in pain with some guarding to their right thigh and was unable to stand. Resident #1 was assisted off the floor with a mechanical lift and two-person assist, then placed in a wheelchair. Physician was made aware and ordered an x-ray of the right hip, pelvis and femur. The x-ray was ordered to be completed by a Mobile / portable, bedside unit Resident #1's family was notified and came in to visit. Vital Signs: Temperature 97. 8, Pulse 83, Respirations 20 per minute, Blood Pressure 160/ 84. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a [MEDICAL CONDITION] femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). There was no documented evidence the facility initiated an investigation on 2/02/2025 to rule out abuse. Additionally, there was no documented evidence the facility completed a thorough investigation of the alleged violation, and no documented evidence that the facility informed law enforcement. Facility 5-day Investigation Report created 02/07/2025 and changed 02/11/2025 documented the following: There was reasonable cause to believe that abuse, neglect, or mistreatment occurred on 02/02/ 2025. Resident representative was reported of the incident on 02/05/2025 at 1:30 PM (three days later). Summary of interview(s) with staff responsible for oversight and supervision of the location where the alleged victim resides listed as, ' NA. ' Summary of interview(s) with staff responsible for oversight and supervision of the alleged perpetrator, if staff or a resident, listed as, ' NA. ' The facility corrective action noted only the termination of employment for Shahbaz # 1. During an interview on 02/11/2025 at 9:01 AM, Assistant Director of Nursing #1 stated Resident #1 had a fall with an injury on 02/02/2025, and video of the incident was reviewed with Guide #1 on 02/03/2025 at 10:50 AM, when abuse was discovered. They stated that Shahbaz #1 was interviewed by telephone and suspended when their recounting of the events that occurred did not match the actual events documented in the video recorded on 02/02/2025 at 5:00 PM. Assistant Director of Nursing #1 stated they then reported it to New York State Department of Health. During an interview on 02/11/2025 at 9:05 AM, Administrator #1 stated that they became aware of the incident on 02/03/2025 at 10:50 AM, when Assistant Director of Nursing #1 notified them that abuse had occurred, and the investigation was not started on 2/02/ 2025. During an interview on 02/11/2025 at 2:17 PM, Shahbaz #2 stated they were afraid and intimidated by Shahbaz # 1. Shahbaz #2 stated they saw Shahbaz #1 grab Resident #1 and pull them away from the table. Shahbaz #2 stated that they thought Shahbaz #1 was taking the resident to their room and did not intervene. They stated that they heard Resident #1 talk loudly and heard Resident #1 fall but did not see it. The resident fell hard; I didn't report it until later because I was scared; I reported it to Licensed Practical Nurse #2 later that night on 02/02/2025 when they arrived at 7:00 PM. The Shahbaz said that Licensed Practical Nurse #2 called the Assistant Director of Nursing #1 and insisted I tell them I had concerns about the fall, and thought they should look at the video because something was not right. During an interview on 02/11/2025 at 11:35 AM, Guide #1 stated they were contacted by Assistant Director of Nursing #1 at approximately 9:30 PM on 02/02/2025 about a fall in the house where Resident #1 resided and where Shahbaz #1 worked. Guide #1 stated Assistant Director of Nursing #1 wanted to know if Shahbaz #1 was working on 02/03/ 2025. Guide #1 stated they informed Assistant Director of Nursing #1 that Shahbaz #1 was not working the next day, and both decided to not review the video until 02/03/ 2025. Guide #1 stated they and Assistant Director of Nursing #1 reviewed the video on 02/03/2025 at approximately 10:30 AM and found that Shahbaz #1 had abused Resident # 1. Guide #1 further stated that they interviewed Shahbaz #1 about the incident by phone; the account given by Shahbaz #1 was not consistent with the video. Guide #1 stated Shahbaz #1 was suspended pending the outcome of the investigation and subsequently terminated. There was no documented evidence the facility took measures to prevent further potential abuse by Shahbaz #1 on 02/02/ 2025. Based on observations, interview and record review cross referenced, when Shahbaz #2 heard the incident as it unfolded, they did not intervene and did not share the status of what had happened with responding staff (Licensed Practical Nurse # 1, Registered Nurse #1, and Shahbaz #3) while the resident was on the ground. Video surveillance footage revealed that after the fall, Resident #1 was animated whenever Shahbaz | Plan of Correction: ApprovedMarch 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction Element 1 Resident 1 was provided with medical intervention at time of incident. Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed to determine if any changes to routine patterns were documented none identified. Law enforcement notified of event. Resident 2 Resident discharged on ,[DATE]/ 25. Staff involved no longer at facility. Full investigation completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25 Resident 3 Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented none identified. Full investigation completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25 Element 2 All residents have potential to be affected by stated deficiency. All Residents that reside in the facility will be interviewed by social work to determine if they feel safe in the facility. Any concerns will be investigated and reported as required. Nursing and social work will monitor the identified residents for potential adverse effects related to allegations IE. mood/behavioral changes, changes in daily routine, etc. The past 30 days of Incident Reports were reviewed by the Director of Nursing to determine thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrence. Review will be completed by 3/27/25 No follow-up action required All staff were in serviced by the nursing educators on 2/12/25 - 2/13/25 on Investigation of allegations of abuse, neglect and mistreatment. Element 3 Measures taken to ensure the problem does not recur: The Abuse Reporting/Investigation policy and procedure were reviewed by the Administrator, Director of Nursing and Nursing Administration. The abuse reporting/investigation policy changed to reflect need to report immediately but not more than two hours all allegations of abuse, neglect and mistreatment. Supervisors have been educated to the process to report and given standard work instructions outlining process. This includes the following: *Notify Administrator *Notify Director of Nursing *Submit report to Department of Health *Notify Law Enforcement Social work, nursing supervisor, nurse manager, assistant director of nursing, director of nursing and administrator were educated on completing the Investigation Checklist for Allegation of Resident Abuse, Neglect, or Mistreatment contained in the Abuse Reporting Policy. By completing all elements of the checklist, it will provide a thorough review of incident and ability for staff to make appropriate corrective actions to prevent reoccurrence of event. The review of the Investigation Checklist includes but not limited to the following: Notification of Administrator and Director of Nursing Accused removed from assignment/suspended until investigation complete Incident Report/Resident Statement Statement of accused/witness statements Face sheet/[DIAGNOSES REDACTED]. Residents most recent History and physical Current physician's orders [REDACTED]. progress notes Care plan related to incident/Kardex reviewed or revised Brief interview for mental status assessment Most recent Minimum data set X-ray reports Staffing assignments Copy of acknowledgement of submission to Department of Health A record of interviews An explanation of evidence reviewed * Police report if appropriate per Elder Justice Act The conclusion reached based on above elements and data points collected during the investigation. The conclusion is drawn following a thorough and complete investigation where critical thinking is used to review investigation and determine actions that need to be taken to prevent reoccurrence of the incident. The above education will be repeated yearly and is part of onboarding for previously identified staff. All open investigations will have a shift-to-shift hand off to next senior leader (supervisor, director of nursing, administrator, or designee) to continue investigation until all elements complete to ensure investigation is completed and closed. Any step in process missed by staff involved in investigation will receive immediate re-education by administrator or designee. Element 4 The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Administrator or designee will update and maintain Investigation Log at the time of each event to ensure that facility appropriately responds and investigates allegations of potential misconduct per policy. Log will document elements including but not limited to the following: 1 Date incident reported 2. Resident demographics 3. type of event 4. If reportable reported within time frame 5. Investigation checklist completed 6. Conclusion 7. If any deficient practice identified remediation/education provided Log will be audited by Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and reeducation provided. Audits will continue weekly for three months. Log will be brought to Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy or education based on results of audits. Committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY 986, NY 919, NY 950, and NY 114), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 (Resident # ' s 1, 2, 3 and 4) of 4 residents reviewed for abuse and neglect. Specifically, (1) an allegation of abuse of Resident #1 ?óÔé¼ÔÇ£ overheard by staff and that resulted in a broken leg ?óÔé¼ÔÇ£ on 02/02/2025 at 5:00 PM was not reported to the New York State Department of Health until 02/03/2025 at 12:55 PM. (2) An allegation of abuse of Resident #2 ?óÔé¼ÔÇ£ that resulted in a broken shoulder ?óÔé¼ÔÇ£ on 11/04/2024 was not reported to the New York State Department of Health until 11/08/ 2024. (3) An allegation of verbal abuse on Resident #3 that was witnessed by staff on 11/05/2024 was not reported to the New York State Department of Health until 11/08/ 2024. (4) An allegation of physical abuse on Resident #4 that was first made known to staff on 11/09/2024 was not reported to the New York State Department of Health until 11/11/ 2024. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F610: Investigate/Prevent/Correct Alleged Violations. Review of facility Abuse Prevention & Investigation Policy dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above). - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and Trinity Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. - a. A report to the New York State Department of Health must be made immediately, but no later than 2 hours after forming the suspicion that an allegation meets the following criteria: Serious bodily injury occurred (regardless of infraction type, e.g., neglect, exploitation, misappropriation, etc.) and/or if there is suspicion that abuse has occurred. b. A report to the New York Department of Health must be made no later than 24 hours after forming the suspicion that an allegation has occurred that: Serious bodily injury did NOT occur, and the allegation involves neglect, exploitation, mistreatment, and misappropriation that does not result in serious bodily injury. c. Failure to report such incidents is considered a violation of regulations and policies governing resident abuse and compromises the facility ' s ability to provide a safe and secure environment for residents. Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident could usually be understood and could usually understand others with severely impaired cognition. Video surveillance footage revealed that on 02/02/2025 at 5:00 PM, Shahbaz #1 pushed Resident #1 and walked away. Resident #1 fell and sustained a fractured (broken) hip. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a [MEDICAL CONDITION] femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). During a telephone interview on 2/12/2025 at 6:49 AM, Registered Nurse #1 stated upon receiving the report of the x-ray on 2/02/2025, they became concerned with Shahbaz #1's accounting of the fall. They stated they had not been present when the fall occurred, but Shahbaz #1 was interacting with the resident. Registered Nurse #1 stated they called the Assistant Director of Nursing #1 to verbalize concerns, and requested the video be reviewed. Registered Nurse #1 stated they did not interview any staff. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, and they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/ 2025. During an interview on 2/13/2025 at 4:08 PM, Administrator #1 stated the complaint with abuse that occurred on 2/02/2025 to Resident #1 was reportable and had not been investigated or reported per regulation by Assistant Director of Nursing # 1. They further stated Assistant Director of Nursing #1 had not notified them and had not followed the procedure in place to protect the resident; Reporting should have been completed on 2/02/2025 two hours after it the allegation was made that abuse was suspected; The video should have been viewed when the concern was raised by the staff especially given the serious injury. There was no documented evidence that the facility notified law enforcement. Record review revealed the facility submitted the Reportable Incident to the New York State Department of Health one day after the event, on 02/03/2025 at 12:55 PM. Resident #2 Resident #2 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented resident could usually be understood and could usually understand others with severely impaired cognition for activities of daily living. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified the resident sustained [REDACTED]. During a telephone interview on 2/20/2025 at 9:08 AM, Guide #1 stated videos were to be reviewed if there was a fall or injury or any questionable situation immediately, and that was not being done. Guide #1 further stated investigations and reporting were done by the Assistant Director of Nursing, Director of Nursing, or A | Plan of Correction: ApprovedMarch 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction Element 1 Resident 1 was provided with medical intervention at time of incident. Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on (MONTH) 21, 2025, to determine if any changes to routine patterns were documented none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact ( i.e. withdrawal. decrease appetite, change in sleep patterns) due to this event. Resident 2 Resident discharged on [DATE] Resident 3 Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact ( i.e. withdrawal. decrease appetite, change in sleep patterns) due to this event. Resident 4 Resident 4 was interviewed on 3/20/25 to determine if they feel safe in the facility. Resident stated she does. Resident will be monitored and observed for any signs of psychosocial stressors related to this incident. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact ( i.e. withdrawal. decrease appetite, change in sleep patterns) due to this event. Staff cited in deficiency are no longer employed by the facility and appropriate referrals made to law enforcement and/or Office of professional discipline Element 2 All residents have the potential to be affected by stated deficiency. All residents that reside in the facility will be interviewed by social work or designee to determine if they feel safe in the facility. Any concerns will be investigated and reported as required under New York State Department of Health reporting requirements. Interviews will be completed by (MONTH) 26, 2025. For any resident who is unable to be interviewed the responsible party will be contacted to determine any concerns. These contacts will be completed by (MONTH) 26, 2025. Nursing and social work will monitor the identified residents for potential adverse effects related to the to the stated deficient practice The past 30 days of incident reports will be reviewed by the Director of nursing or designee to determine thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrences Review will be completed by (MONTH) 26, 2025. If any areas are identified as being inconsistent with policy further investigation will be completed at time of review and if required incident reported to regulatory body per regulation and policy. All staff were educated on 2/12/25 -2/13/25 on abuse reporting requirements and abuse reporting policy Element 3 Measures taken to ensure the practice does not reoccur: *The abuse reporting/investigation policy was reviewed by the administrator, Director of nursing, and nursing administration. The policy was revised. Policy updated to state all staff have responsibility to immediately report any abuse/allegation of neglect, mistreatment or misappropriation. Policy also updated to clarify need to report all allegations within 2 hours to New York State Department of Health and as appropriate other regulatory entities. Education provided to Social work, nursing supervisor, nurse managers, and administrator and all staff by a third party consultant as part of a directed Inservice plan. Education included but not limited to the following: Definitions of abuse, neglect and mistreatment Reporting timeline Reporting obligations Investigation. The above education will be repeated yearly and is part of onboarding. All investigations will have a shift-to-shift hand off to the next senior leader (Supervisor, Director of Nursing, administrator, designee) to continue the investigation until all elements are complete to ensure investigation is completed and closed. Any steps in process missed by staff completing the investigation will receive immediate re-education by administrator or designee. Review of the Centers for Medicare and Medicaid (CMS) Critical Element Pathway with the Registered Nurse Supervisory staff to ensure full understanding of the reporting requirements. Standard work instruction developed for use by the supervisor to ensure he/she have the tools needed to report all allegations/suspected/actual incidents of abuse per policy (Immediately but no later than 2 hours) and to assist in the thorough investigation of all incidents. Element 4 The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Audits will be completed on 5 elders and 5 staff per week. Elders will be asked if they feel safe and if they have any concerns regarding staff or care. Audits will be completed by social work or designee. Staff will be audited on his/her knowledge of abuse reporting requirements. Staff audits will be done by Nurse Manager or designee on varying shifts. Any areas identified that require follow-up or education will be done immediately. Audits be completed weekly for the first three months. Audits will be brought to the Quality Assurance Committe monthly. Committee will make recommendations based on audit results. Administrator or designee will update and maintain Investigation Log at the time of each event to ensure that facility appropriately respond and reports allegations of abuse, neglect or mistreatment. Log will document elements including but not limited to the following: 1 Date incident reported 2. Resident demographics 3. type of event 4. If reportable reported within time frame 5. Conclusion 6. If any deficient practice identified remediation/education provided Log will be audited by Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and reeducation provided. Audits will continue weekly for three months. Log will be brought to Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy or education based on results of audits. Committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance |