Westgate Nursing Home

Based on record reviews and staff interviews conducted during an Abbreviated Survey (complaint #NY00095831) completed on 1/18/11, it was determined that for one of two residents reviewed for an injury of unknown origin, the facility did not thoroughly investigate in a timely manner to rule out abuse, neglect, or mistreatment. This affected Resident #1, and resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #1 has diagnoses including osteoarthritis, osteopenia, and peripheral vascular disease. The Personal Care Profile, dated December 2010, revealed that the resident required the assistance of one for ambulation with a rolling walker.

Nursing progress notes dated 12/25/10 revealed:

a) A Licensed Practical Nurse (LPN) noted at 2:30 p.m. that the resident complained of left ankle pain, and when the left ankle was observed, it was red in color and swollen. The Supervisor (an LPN) was notified at the time and recommended cold compresses applied to the ankle.

b) A LPN during the 3:00 p.m. to 11:00 p.m. shift noted that the resident continued to complain of left ankle pain and that the cold compresses were applied to the resident's elevated left leg.

The nursing 24-hour report for 12/25/10 did not include any reference to the resident's left ankle swelling or pain. There was no documentation in the medical record to show that the evening Nursing Supervisor, a Registered Nurse (RN), had observed the resident's ankle to evaluate the resident's reported pain or had initiated an investigation.

In a nursing progress note dated 12/26/10 at 6:00 p.m., an RN documented an assessment of the resident's left foot and left ankle, revealing left foot and ankle swelling, pain with palpation (touch) and any slight movement, pain level a 10 out of 10 (10 being the worst pain).

On 1/12/11 the facility provided a folder with an Incident and Accident report initiated on 12/26/10 at 6:00 p.m. which included a partially completed investigation. This investigation lacked an interview with the RN Supervisor who initiated the Incident/Accident Report on 12/26/10 and a conclusion regarding alleged abuse, neglect, or mistreatment.

When interviewed on 1/12/11 at 3:15 p.m., the Consultant RN stated that she spoke to the Evening RN Supervisor about the incident and she thought that she wrote a statement but could not provide one at the time. The Consultant RN said the investigation was incomplete because they had not been able to interview the CNA, who reported that she bumped the resident's leg on 12/25/10.

The facility's policy regarding reporting/investigating resident accidents/incidents directs that an Incident/Accident Report must be completed on the shift in which the accident/incident occurred. All incidents or accidents involving residents must be thoroughly documented in the resident's medical record. The resident's attending physician and Medical Director will be promptly notified when the resident is involved in an accident/incident. All incidents must be on the 24-hour report for three days.

[10 NYCRR 415.4(b)(2)]

Based on observations, resident and staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY00095831) completed on 1/18/11, it was determined that for one of two residents reviewed for quality of care, the facility did not provide the necessary care and services to attain and maintain a resident's highest practicable well being. The issues involved an injury to a resident's left ankle which was not assessed in a timely manner by nursing staff and resulted in a delay in treatment. The physician was not notified for further treatment alternatives and pain management until two days after the injury occurred. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #1 has diagnoses including osteoporosis, osteopenia, and peripheral vascular disease. The Minimum Data Set Assessment, dated 1/5/11, revealed that the resident's cognitive skills for daily decision making are moderately impaired.

The Personal Care Profile, dated December 2010, documented that the resident required one assist with transfers and ambulation with a rolling walker to walk ten feet. The Personal Care Profile, dated 12/28/10, documented that the resident was nonweight bearing and needed the assist of two using a mechanical lift to be transferred. The Certified Nursing Assistant (CNA) Activities of Daily Living flow sheet for the month of December 2010 revealed that the resident's ambulation activity was recorded as requiring the extensive assistance of one in the room from 12/1 through 12/26/10, and from 12/27 through 12/31/10, the resident did not ambulate.

Nursing notes, dated 12/25/10, revealed the following:

a) A Licensed Practical Nurse (LPN) noted at 2:30 p.m. that the resident complained of left ankle pain and when observed, the left ankle was red in color and swollen. The resident was still able to transfer, and routine Tylenol (APAP) was being given. The LPN documented that when the Nursing Supervisor (LPN) was notified, she was instructed to apply cold compresses to the resident's ankle. The LPN also documented the resident's issue in the Physician Assistant book for further follow-up.

b) A LPN noted during the 3:00 p.m. - 11:00 p.m. shift that the resident continued to complain of pain. The LPN documented that the resident's left ankle was elevated, cold compresses were applied, and the resident was given scheduled APAP.

c) The nursing 24-hour report for the 12/25/10 day shift did not include any reference to Resident #1's left ankle pain.

There was no documentation in the medical record to show that the evening supervisor observed the resident's ankle to evaluate the resident's reported pain, initiated an investigation, or contacted the physician on 12/25/10.

In a nursing progress note of 12/26/10 at 6:00 p.m., a Registered Nurse (RN) documented that the resident's left ankle and foot was swollen and that the resident was experiencing pain upon touch and any slight movement. The RN noted that the resident's pain level measured 10 out of 10; 10 represents the highest pain level. The RN also included in her note that the plan was to offer the resident pain medication as ordered and as necessary, to monitor, keep feet elevated on pillow, and check with Nurse Practitioner/Physician Assistant in the morning regarding the left foot.

The December 2010 Medication Administration Record showed no evidence that any as necessary pain medications were ordered or given.

An Incident and Accident Report, dated 12/26/10 at 6:00 p.m., signed by the RN Supervisor, revealed the evening nurse reported to her that the resident's left foot and ankle were swollen. The RN Supervisor assessed the foot and ankle and documented preventative action was to keep the resident in bed with a pillow under her feet.

There was no evidence in the medical record to show that a physician had been contacted regarding the resident's swollen left ankle and foot on 12/26/10.

A 12/27/10, 11:00 p.m. to 7:00 a.m. nursing progress note revealed that at 6:30 a.m., a CNA got the resident out of bed. At this time, the resident complained of pain, and her left ankle was still swollen. The CNA put the resident back to bed.

A 12/27/10, 11:00 a.m. nursing progress note recorded that when the nurse asked the resident if she could look at her left ankle, the resident responded that it hurt and told the nurse not to touch it. The nurse called the physician to report that the left ankle was swollen and painful to touch. The physician ordered an x-ray of the left ankle and foot. The physician was called again when the x-ray results were positive for a nondisplaced fracture. At this time, the physician ordered an orthopedic consult for that day and Percocet (pain medication) for pain.

The Orthopedic Consultation Report, dated 12/27/10 at 3:40 p.m., revealed that the resident had sustained a fracture of the tibia/fibula (two bones of the lower leg) of the left leg which required casting and a nonweight bearing status.

During an observation on 1/12/11 at 9:45 a.m. the resident was seated in a wheelchair. Her left leg was casted in a full leg cast and was elevated on a pillow. When asked if she could move her toes on the left foot, she was unable to demonstrate any movement in those toes but at the same time did not complain of pain.

In an interview on 1/12/11 at 1:40 p.m., the Assistant Director of Nursing reported that staff are expected to call the Strong Medical Group to report acute medical issues and when they do, a Physician, Nurse Practitioner, or Physician Assistant, will call them back to address these issues.

When interviewed on 1/12/11 at 1:45 p.m., the Nurse Manager (a LPN), who was the day Supervisor on 12/25/10, stated that around 2:30 p.m. he recalls LPN #1 telling him about the resident's foot/ankle. He did tell the LPN to elevate the foot, apply cold compress, medicate the resident, and he reported the issue to the oncoming Evening Supervisor (an RN). The Nurse Manager said he did not observe the resident's foot himself.

During an interview on 1/12/11 at 3:15 p.m., the Consultant Nurse stated that she thought the Evening RN Supervisor that worked on 12/25/10 had written a statement regarding the incident but was not able to provide it to the surveyor. The Consultant Nurse stated that she had spoken to the Evening RN Supervisor about the incident and had learned that the reason the RN Supervisor did not call the physician on 12/25/10 and 12/26/10 was that she thought that the pain and swelling was from the resident's osteoarthritis.

[10 NYCRR 415.12]