Our Lady of Mercy Life Center
Deficiency Details, Certification Survey, June 7, 2011
Regional Office: Capital District Regional 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: August 5, 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: June 7, 2011
Based on record review and staff interview the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source were thoroughly investigated for 2 (# 44 and 59) of 7 residents reviewed for incidents requiring investigation. Specifically, for resident a fall with fracture was not thoroughly investigated, and for bruises of unknown origin were not investigated. This resulted in no actual harm with the potential for more then minimal harm that is not immediate jeopardy. The findings are:
The resident was admitted on 9/22/11 with the diagnosis of dementia, pulmonary hypertension, and osteoporosis. The Minimum Data Set (MDS) dated 3/16/11 assessed the resident as being severely cognitively impaired.
The nurses notes dated 5/15/11 at 10:16 pm documented that the resident was found lying on the floor,on the left side, facing the window at 7:10 am. The resident was noted to have blood on her gown and on the floor. A laceration was noted on the bridge of the residents nose, and on the left side of the nose. The residents bed alarm was documented to have been unplugged from beneath the bed, and did not sound. A note dated 5/15/11 at 2:51 pm, documented that a new order was received to send the resident to the emergency room. for evaluation of redness and swelling to face related to the fall. A note dated 5/15/11 5:30 pm documented that the emergency room had contacted the facility with results of a CT scan ( X-ray views taken from many different angles to produce cross-sectional images of the bones and soft tissues inside the body), which were positive for a nasal bone fracture.
The the post fall investigation form dated 5/15/11 documented that the fall occurred at 7:10 am in the residents room and was unobserved. The bed was locked and floor mats were in place. The bed alarm was on but did not sound, it was disconnected under the bed. The Registered Nurse (RN) assessment noted that the resident had an abrasion and laceration to the bridge of her nose, and was exhibiting moderate swelling and bruising to left facial region and eye. The wound was cleaned and dry sterile dressing was applied, ice packs to reduce swelling. The resident refused to go to the hospital. Family was notified. On 5/16/11 the team reviewed the incident and decided to move the resident to a room closer to the nurses station and a low bed was added.
During an interview on 6/2/11 at 12:00 pm, the Director of Nurses (DON) stated that she did not believe that an investigation had been completed, but she would check. At 12:30 pm she approached the surveyor and stated an investigation had not been completed.
During a second interview with the DON on 6/6/11 at 8:45 am, she noted that there has not been a nurse manager on the unit for a couple of months. She stated that the incident required more looking into, and this had not occurred.
The resident was admitted on 4/14/10 with the diagnosis of hypertension, traumatic brain injury, and anemia. The MDS dated 3/16/11 assessed the resident as having severe cognitive impairment.
The nurses notes dated 5/17/11 at 10:48 am, documented that bruises were observed to the left and right inner calves. A skin tracking sheet was initiated.
The Occurrence Report for Resident Related Incidents dated 5/17/11 at 8:00 am, documented that there were 5 cm x 5 cm bruises found on the right posterior calf with a movable lump above the bruise. Also noted was an 8 cm x 2 cm bruise on left inner calf. Under contributing factors, it was documented that the resident often is restless and stands brushing legs against wheelchair.
During an interview with the DON on 6/6/11 at 1:00 pm she stated that no statements regarding the bruises had been obtained. After reviewing the occurrence report, the DON stated that it was not complete. She stated that at the time the occurrence occurred she didn't feel that an investigation was necessary, but looking back one should have been completed. She identified that no description of the bruises had been documented anywhere. She stated she was unable to say what occurred in this case. She also stated she recognized that the facility's process for investigating incidents needed work.