Abuse Incident During Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, as evidenced by an incident involving a cognitively impaired resident during medication administration. Video surveillance captured a Licensed Practical Nurse (LPN) forcefully tilting the resident's head back, holding their nose, and shoving a spoon into their mouth. The LPN was also seen kicking the back wheel of the resident's wheelchair and pushing it against a table, locking it in position. This incident occurred in the dining room, where the resident was seated alone at a table. The resident, who was re-admitted with unspecified diagnoses, had a care plan in place to prevent abuse, which was not adhered to during this incident. The video footage showed the LPN's aggressive actions, including shoving the resident's wheelchair against a wall. A Certified Nurse Aide (CNA) present during the incident did not intervene or report the abuse immediately, although they later acknowledged witnessing the LPN's inappropriate behavior. The incident was brought to the attention of the facility's administration the following day when another CNA reported witnessing the LPN kicking the resident's wheelchair. This prompted a review of the video footage and subsequent investigation. The facility's failure to protect the resident from abuse and ensure staff adherence to the abuse prevention care plan resulted in a deficiency citation.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 No Plan of Correction is required. By copy of this notice received on (MONTH) 25, 2025, from the Metropolitan Area Office, this office is informing the facility Administrator and the CMS of the Immediate Jeopardy findings and Substandard Quality of Care. The facility employed corrective measures prior to the survey that removed the IJ identified on 02/26/2025. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance on 2/27/2025 and was in substantial compliance for this specific regulatory requirement at the time of this survey. The facility will continue our training, audits, and QAPI monitoring to ensure this deficient practice will not recur.
Removal Plan
- A full investigation was started after administration viewed the video.
- Staff that were on the unit during the incident were brought to the conference room.
- The three accused staff were suspended.
- Accused Licensed Practical Nurse #1 was terminated.
- Information about the incident was sent to the NYS Education Department and Office of Professionals.
- The name of Licensed Practical Nurse #1 is with local authorities with a case open and an open order of protection.
- The Abuse care plan was updated.
- The interdisciplinary team discussed the allegation of abuse with the resident.
- Attending Physician performed an assessment with no negative findings.
- Resident #1 was placed on 1:1 monitoring.
- The Director of Nursing called the family of Resident #1.
- All other residents were evaluated and assessed.
- Social workers began interviewing the residents to ensure they felt safe.
- Residents were instructed on how to report abuse or any concerns they might have.
- Residents were given the phone number for the Department of Health as well as the Ombudsman.
- Met with the Resident Council to ensure all residents are aware of how to report abuse.
- Interview with Resident Council president confirmed that they were all spoken with about abuse and how to report it.
- Residents were given business cards with phone numbers.
- All other staff have been educated on the importance of informing/reporting immediately and protecting the residents in their care.
- After incident in-service with a final complete 100% attendance.
- An Ad Hoc Quality Assurance Performance Improvement meeting was held.
- Suspension and termination, re-education for abuse prevention with a concentration on removal of resident and immediate reporting were discussed.
- Calling family with update was addressed.
- Dining room and feeding competencies were addressed.
- Another Quality Assurance Performance Improvement meeting and morning report continued the 1:1 monitoring, reviewed medication and care for resident.