Wayne County Nursing Home

Based on staff interviews and record review conducted during an Abbreviated Survey (complaint #NY00102867) completed on 6/30/11, it was determined that for one of three residents reviewed for abuse and neglect, the facility did not thoroughly investigate injuries of unknown origin to rule out resident abuse, neglect, or mistreatment. The issue involved lack of thorough investigation of an injury of unknown origin for Resident #1. 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 cerebral vascular accident with left hemiparesis, uncontrolled diabetes, hypertension, and organic personality disorder. The Minimum Data Set (MDS) Assessment, dated 4/27/11, revealed that the resident's cognition is severely impaired. The current Certified Nursing Assistant (CNA) Summary shows that the resident is independent with transfers with use of an ankle brace to left leg, and bed enablers for bed mobility on both sides of the bed.

A 6/19/11 nursing progress note documented that at 5:20 a.m. that day, staff discovered that the resident had sustained an abrasion to the left side of the forehead measuring 1 centimeter (cm) x 0.5 cm and an abrasion to the left knee measuring 1.6 cm x 1.2 cm. The Registered Nurse (RN) nursing supervisor was notified, the abrasions were cleansed, triple antibiotic ointment was applied to the areas, and neurological checks were started. The neurological checks revealed that the resident's hand grips were within normal limits, the resident responded appropriately, and the right eyelid was noted to be droopy. This information was placed on the physician's board and was reported to the oncoming nursing shift.

A 6/19/11 nursing progress note entered at 6:31 a.m. by the night RN Supervisor documented that the Licensed Practical Nurse (LPN) had notified her of the abrasions on the resident's left forehead with hematoma and abrasion to the left knee. Neurological checks revealed that the resident's pupils were sluggish and that the resident answered questions appropriately.

Review of the I&A Report, dated 6/19/11, does not include a time of the incident but includes the incident was discovered by a CNA at 5:10 a.m., at the start to the last rounds. The form was signed by the RN Nursing Supervisor on 6/19/11.

On 6/29/11 at 9:30 a.m., the resident was observed in a wheelchair with a leg brace on his left lower leg. The resident was using the computer in the common area outside of his room. His left eyelid was slightly drooped. The resident was able to state his name.

When interviewed on 6/29/11 at 11:45 a.m., the Director of Nursing (DON) stated that she could not find an Incident and Accident (I&A) Report, dated 6/19/11, for this resident.

During an interview on 6/29/11 at 11:55 a.m., the RN Night Supervisor reported that she remembered the I&A Report being initiated on 6/19/11 by the LPN but could not recall documenting on the form.

When interviewed on 6/30/11 at 8:30 a.m., the DON stated that she had spoken to the Night LPN who worked the night of 6/19/11, and said that she had the I&A report in her bag. The DON had the report with her and said she recalls reviewing the report and giving it back to the nurse for investigation, which was not completed.

During an interview on 6/30/11 at 1:35 p.m., the Night LPN said that she did initiate an I&A Report on 6/19/11. The RN Night Supervisor had signed the report and then she put it in the Charge Nurse's basket the morning of 6/19/11. She added that on 6/26/11 she received an envelope containing the original I&A Report with a note to complete the investigation. On 6/27/11, she got the incident packet to complete the investigation. She did not have time to do all of the things in the packet, so she put the I&A Report in her nursing bag so that it would not get lost.

The facility policy entitled, "Charting on Residents with Injury/Falls," reviewed/revised in October 2007, revealed that a full body assessment from head to toe will be done by the RN and that the healthcare provider is to be notified immediately if injury is significant and involves any change in condition.

The facility policy entitled, "Accident and Incident Reports," reviewed/revised February 2011, revealed that the Charge Nurse, Nurse Manager, Supervisor or licensed staff will be notified immediately to initiate a continued investigation, including vital signs, of resident at the scene and investigation report. The investigation will be completed within 72 hours and submitted to the Department Director.

[10 NYCRR 415.4(b)(1)(ii)]

Based on record review and staff interviews conducted during an Abbreviated Survey (complaint #NY00102687) completed on 6/30/11, it was determined that one of three residents reviewed for assessment did not receive services by qualified persons. Specifically, a physician was not notified in a timely manner when Resident #1 presented with apnea (periods of breathlessness during sleep) and a head injury. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #1 has diagnoses including cerebral vascular accident with left hemiparesis, hypertension, and uncontrolled diabetes. The current physician orders include oxygen at 2 liters (L) via nasal cannula as needed for shortness of breath or saturations below 92 percent.

Review of a 6/19/11 night Licensed Practical Nurse (LPN) nursing note revealed that the resident presented with periods of apnea while sleeping. His lips and face were dusky in color. Oxygen saturation levels obtained were 95 percent to 89 percent on room air. This information was placed on the physician board and was reported to the night Registered Nurse (RN) supervisor. Also at 5:20 a.m., the resident was found by staff with an abrasion to the left side of his forehead and left knee and a lump to the left side of his head. Vital signs were taken, neuro checks were initiated, triple antibiotic ointment was applied to the abrasions, and an ice pack was applied to the head. Neuro checks revealed that hand grips were within normal limits, responses were appropriate, and the right eyelid was droopy. This information was placed on the physician board and was reported to the night RN supervisor and to the oncoming shift. There was no documented evidence that oxygen was applied when oxygen saturation rates fell below 92 percent.

Review of the night RN supervisor progress note, dated 6/19/11, revealed that the RN supervisor assessed the resident but did not document a call to a physician to report the resident's condition.

The LPNs on the day and evening shifts of 6/19/11 documented that neuro checks were within normal limits, however, made no reference to a physician contact.

The 6/19/11 evening nursing note includes neuro checks within normal limits, and the resident had no complaints of pain or discomfort during the evening shift.

Nursing progress notes, dated 6/20/11, revealed the night LPN documented that the resident had a blood pressure reading of 170/92. A repeat blood pressure taken with a manual blood pressure cuff measured 158/92. Neurological checks were identified that the resident's right eye was droopy. The night RN supervisor noted the resident's blood pressure was 170/90. The resident had a hematoma and an abrasion on the top of his head. Neurological assessment identified that the resident's right eyelid was droopy. A blood pressure taken with a manual cuff measured 158/90. The RN supervisor reported the resident's condition to the day shift including the need for a physician to assess the resident. The RN noted that the physician was called to report the resident's condition. At that time, the physician gave a verbal order to continue neurological checks every four hours for two days and oxygen at 2L via nasal cannula for the sleep apnea. A note was placed on the physician board for the follow-up visit.

Interviews on 6/29/11 revealed the following:

a) At 10:45 a.m., the RN/Nurse Manager (NM) reported that the physician was on the unit doing rounds on 6/23 and 6/24/11. However, she could not say that the resident was seen and was not able to locate a corresponding medical progress note for these days for this resident.

b) At 3:20 p.m., the NM reported that she spoke to the physician who stated that he saw the resident on 6/24/11 in the common area on the unit, but did not complete a dictated note.

[10 NYCRR 415.19(c)(3)(ii)]