Coler-Goldwater Spec Hosp & Nurs Fac Goldwater Nursing Facility Site

Based on observations, interviews and record review, the facility did not ensure professional standards of quality were met. Specifically, a resident was observed on the floor by a Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA). The resident was removed from the floor and put back to bed before assessment by a Registered Nurse or a physician. Once notified about the resident's fall, the Registered Nurse (RN) did not assess the resident and notify the physician. This was evidenced in 1 of 4 sampled residents, (Resident is # 1) during an abbreviated survey.

This resulted in no harm with the potential for more than minimal harm that is not Immediate Jeopardy.

Complaint ID # NY00070016

The finding is:

Resident # 1 is a 60 year old admitted to the facility on 6/01/06. His diagnoses included Carcinoma of the Larynx with Metastasis, Chronic Obstructive Pulmonary Disease (COPD), Anemia and Fracture of the left hip. The Minimum Data Set 2.0 Assessment dated 1/6/09 documented that the resident has independent cognitive skills for daily decision making with no memory impairment. He is independent in Activities of Daily Living (ADL), requires limited assistance in bathing and has Gastrostomy Tube. He communicates with gestures and writing.

The Fall Risk Assessment dated 2/17/09 revealed that the resident is at high risk for falls.

A Comprehensive Care plan (CCP) initiated on 1/20/09 documented that the resident is at risk for fall/injury. Interventions included a low bed, call bell within reach, encourage resident to ambulate with wheelchair for long distances, and observe for any complaints of pain. An actual fall on 3/23/09 is documented on the CCP.

A CCP initiated on 3/23/09 documented that the resident had a non-displaced fracture of the left hip per X-ray result. The resident was discharged to the hospital on 3/25/09 and readmitted on 3/31/09 status post ORIF (Open Reduction Internal Fixation) for left hip fracture.

A Medical Doctor's (MD) note dated 3/24/09 at 11:00 AM documented that the resident was seen by the MD because he complained of falling yesterday and having pain to the left hip area. On assessment the MD noted that the resident had painful movement with tenderness and a bruise to the left arm. The MD ordered an X-ray of the left hip.

An RN note dated 3/24/09 at 12PM documented that at 10:00AM when she was giving medications to the resident, she noted that the resident seemed unhappy and crying. When the RN asked the resident what happened, the resident wrote that he fell down from the bed. When examined by the MD and the nurse, the resident was noted with a bruise to left elbow with dry blood and he complained of pain on the left leg from hip to toe. The Assistant Director of Nursing (ADON) was notified and the MD ordered STAT (immediately) blood works, urine analysis (U/A), urine culture (C+S), Chest X-ray, X-ray to the left hip and pelvis.

An MD progress note dated 3/24/09 at 4PM documented that the X-ray report showed a non-displaced fracture of the left hip. The resident was informed of the X- ray result and he will be transported to the Emergency Room for orthopedic intervention. The resident refused to go to the hospital and stated that he is not interested in any surgical or non-surgical treatment.

An MD progress note dated 3/25/09 at 10:00AM documented that the resident agreed to go to the hospital.

The facility Occurrence Assessment & Investigation from the Nursing department dated 3/26/09 documented that Licensed Practical Nurse (LPN) was informed by the resident's roommate that he resident was on the floor. The LPN and Certified Nursing Assistant (CNA) proceeded to put the resident back to bed via Hoyer lift. The LPN also checked the resident's vital signs which were the normal baseline and wrote them on a piece of paper. The LPN informed the RN of the incident when she returned from a class at about 10:15 PM. Both nurses went back to the resident, but the resident was asleep and could not be awoken as he received Ativan and Percocet earlier that evening. The RN stated that the resident was not in acute distress and was sleeping soundly. She then went back to the nurse's station where she received a phone call instructing her to go to the Nursing office. The RN stated that she forgot about the incident and did not inform the doctor. Investigation conclusion was that the resident had a fracture due to fall. There was a delay in the reporting process which resulted in the delay of treatment/ intervention.

On 1/20/10 at 3:55 PM, a telephone interview was conducted with the MD. The MD stated that the resident claimed that he fell down at night near his bed. The resident complained of left hip pain on movement and a bruise around his elbow without pain or swelling was noted. The MD stated that he told the resident that he will be transferred to the hospital for orthopedic intervention, however, the resident refused to go to the hospital. The MD stated that the resident changed his mind and agreed to go to the hospital on 3/25/09.

On 11/25/09 at 3:25 PM, the RN was interviewed. She stated that on 3/23/09 the LPN told her that the resident fell at 9:30 PM. When she went to assess the resident he was asleep. The RN stated that while she was in the resident's room, she was called by the Associate Director of Nursing (ADON), and then left the unit. She returned to the unit at 11:00PM. The RN stated that she forgot about the incident and she did not write a nurse's note, a 24 Hour Report entry or an Occurrence Report and she did not notify the physician.

On 1/21/10 at 2:45 PM a telephone interview was conducted with the CNA who assisted with putting the resident back to bed after the fall. She stated that on 3/23/09 after 9:00PM, the resident's roommate came out of the room and called out for help. The CNA stated that she and the LPN went to the room and found the resident sitting on the floor. The CNA stated that they put the resident back to bed with a Hoyer lift.

On 2/1/10 at 2:00PM the ADON was interviewed about the facility's fall protocol. She stated that an LPN can assess and observe the resident after a fall. If there is no pain or injury noted after an assessment it is acceptable for the LPN to put the resident back to bed. The ADON stated that in this case the resident told the LPN that he had no pain. The LPN and the CNA proceeded to put the resident back to bed with a Hoyer lift.

415.11 (c) (3) (i)