Avalon Gardens Rehabilitation & Health Care Center, Inc
Deficiency Details, Complaint Survey, October 4, 2011
Regional Office: MARO--Long Island sub-office
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4): NOT EMPLOY PERSONS GUILTY OF ABUSE
Severity: Potential for more than Minimal Harm
Corrected Date: November 25, 2011
The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Citation date: October 4, 2011
Based on observation, record review, and staff interview during the abbreviated survey, the facility did not ensure that each resident with injury of unknown origin was reported in accordance with State Law, New York State (NYS) Department of Health (DOH) through established procedures. Specifically, one (Resident #1) of six sampled residents reviewed for accidents, sustained a large ecchymotic (discolored area of the skin) hematoma (collection of blood) of the left side of the resident's forehead. The Resident's injury was not reported to the DOH. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The Finding is:
Complaint number 00098921
Resident #1 had diagnoses including history for falls and Alzheimer's disease.
The Minimum Data Set (MDS) dated 1/6/11, assessed the resident's cognition as moderately impaired.
The Comprehensive Care Plan (CCP) risk for falls dated 11/18/10, documented history of falls prior to admission. On 11/24/10, the resident was found sitting on the floor near her bed; bed and chair alarm sensors were put into place. On 12/8/11, the resident slid from the wheelchair with no injuries noted. On 12/30/10 a low bed was put into place and on 1/20/11 the resident sustained an ecchymotic hematoma to the left side of the forehead.
The Occurrence Investigative Report Summary dated 1/20/11 at 8:00AM documented that the Certified Nurses Assistant (CNA) noted a hematoma on the resident's left temple. The Registered Nurse (RN) supervisor was notified and the resident was assessed. Vital signs 124/78, 84, 20 and Pupils equal and reactive to light (PERLA) with no lose of consciousness. The Medical Doctor (MD) was notified and stat (right away) facial X rays, laboratory work including a Prothrombin (PT) (laboratory test of the blood to measure clotting factor) and International Normalized Ratio (INR- laboratory test of the blood to measure the effectiveness of blood thinning medications) were ordered. The x ray result dated 1/20/11 documented no bony pathology. The results of the investigation documented that there was no indication the resident had fallen. Both alarms bed and wheelchair were in working order.
The Integrated Progress Notes dated 1/25/11 at 3:00PM documented that the resident was lethargic. The MD was called and ordered to send the resident to the hospital to rule out a subdural hematoma. The resident was transferred and admitted to the hospital at 12:45 PM.
The Hospital Discharge Summary dated 1/25-26/11 documented that the resident was found unresponsive. A Computerized Axial Tomography (CAT) scan of the brain was done and it showed subdural (brain) hematoma with associated right to left midline shift as well as effacement (complete removal of form) of the cisterns (a space serving as a reservoir) in keeping with uncal (a curved structure on the floor of the of the brain) herniation.
The Certificate of Death dated 1/26/11 documented that the immediate cause of death was blunt force head trauma.
The Director of Nursing (DON) was interviewed on 9/19/11 at 3:00PM, the DON stated that on 1/20/11 when the injury to Resident #1's left forehead was identified it was not reported to the NYS DOH.