F0550

D

Resident Left on Floor After Fall and Rough Handling by CNA

Troy, New York Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure a resident’s right to dignity, respect, and care in a manner that promotes quality of life. The facility’s own Resident Handbook states that residents have the right to dignity, respect, a comfortable living environment, quality care without discrimination, freedom of choice, privacy, freedom from abuse and restraints, and the ability to exercise their rights without fear of reprisals. The resident involved had diagnoses including Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. An MDS dated 08/08/2025 documented that this resident could be understood, could understand others, and had intact cognition for decisions of daily living. Care plans directed staff to encourage the resident to ask for assistance, orient the resident to changing surroundings, respect the resident’s right to refuse activities, initiate conversation frequently, maintain preferred independent leisure activities, provide escort or transportation as needed, and, for falls, to investigate the cause of any fall immediately, provide reality orientation, keep the resident in a high-profile area when possible, and report unsafe behavior to nursing.

On the date of the incident, an incident report documented that a CNA observed the resident standing in their room, assisted them to their wheelchair, and that when exiting the room the resident grabbed the wall handrail and pulled themselves from the wheelchair. The CNA’s written account stated that while attempting to reseat the resident, the resident needed to be lowered to the floor to prevent a fall, and that the resident’s self-propelled standing from the wheelchair was attributed to gastric distress. However, the facility’s abuse investigation, which included video footage, showed that the CNA entered the resident’s room without knocking, placed hands on the resident’s arms, and pulled the resident into the wheelchair while the resident appeared to resist. The resident stood again and was again pulled into the wheelchair, nearly missing the chair and almost falling. The video further showed the CNA pushing the resident in the wheelchair while the resident attempted to block the front wheel with their foot, then turning the wheelchair to move it backwards into the hallway.

As the wheelchair was being pulled backwards, the resident stood up and fell to the floor onto their side. The CNA appeared to throw their hands down at their sides and then walked away, leaving the resident lying on the floor. The resident remained alone on the floor for approximately two minutes before the CNA returned in the camera’s view with a mechanical lift, walked past the resident, spoke briefly, and then stood in a nearby doorway at least five feet away. The resident was left unattended on the floor for a minimum of four minutes between 10:49 a.m. and 10:53 a.m. before nursing staff, including an LPN and the Assistant Director of Nursing, arrived and began interacting with and assessing the resident. Interviews with the RN unit manager, the Assistant Director of Nursing, and the Director of Nursing confirmed that staff were expected to treat residents with respect and dignity, that physical redirection was not acceptable, that a CNA who lowered a resident to the floor should stay with the resident and obtain help via call bell or by calling out, and that it was not appropriate to leave a resident unattended on the floor for multiple minutes. The DON stated that the CNA’s actions were not acceptable and not in line with expectations for kind and dignified treatment.