Dr William O Benenson Rehab Pavilion

Based on observation, staff interviews and record review, the facility did not ensure that each resident receives the necessary care and services to maintain his/her highest practicable physical well-being. This was evidenced in 2 of 8 sampled residents. A) One resident (#1) sustained a fall and complained of pain to the left hip; the resident was not assessed by the Registered Nurse (RN) despite the resident complaint of pain and B) One Resident (#5) was observed sitting on the floor by a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA); the resident was removed from the floor and placed in a wheelchair by the staff prior to being assessed by a RN or a physician.(Residents # 1 and # 5).

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

Complaint ID #s NY00083766 and NY00068348

The findings are:

A) Resident # 1 is an 85 year old admitted to the facility on 1/10/08. Her diagnoses include Dementia, Ramus Fracture, Osteoporosis and Osteopenia. The Minimum Data Set Assessment (MDS) 2.0 dated 2/24/10 identified the resident with short term memory impairment, modified independence in cognitive skills for daily decision making, requires extensive assistance in personal hygiene, toileting and transfer with one staff assist and supervision in locomotion on the unit in wheel chair.

On 3/26/10 at 10:55 AM Resident was observed in bed with a bluish discoloration to the left hip.

The Occurrence Report dated 3/20/10 at 9:20 PM documented that the CNA responded to a sounding alarm and observed the resident lying on floor in the hallway in front of her wheel chair. The resident complained of pain to the left leg. The doctor was notified at 9:32 PM and an x-ray of the left hip was ordered.

Review of the unit surveillance video tape of 3/20/10 beginning at 9:00 PM on 3/30/10 revealed that at 9:08 PM LPN #1 approached the resident from behind and held on to both handles of the wheel chair. She abruptly pulled the wheel chair to the left. The resident fell on the floor in front of her wheel chair. LPN # 1 walked around the resident, began looking around the unit, and then left the area. At 9:10 PM CNA # 1 came in front of the Nurse's station and observed the resident on the floor. He stood in front of the station with his back towards the resident and appeared to be talking to someone and pointing towards the resident's direction. At 9:11 PM LPN # 1 went inside the Nurse's station and made a phone call. At 9:12 PM a Nursing Supervisor (RNS # 2) arrived to the unit and went to the resident who was still lying on the floor. LPN # 1 and CNA # 1 went to the resident and RNS # 2 was talking to them. In less than 30 seconds, the LPN and the CNA picked up the resident off the floor and placed her in her wheel chair. RNS # 2 began moving the resident's extremities up and down while the resident was in the wheel chair. The staff then walked away from the resident. The resident was left sitting in the wheel chair. At 9:14 PM the resident wheeled herself on the unit. She tried to raise her left leg twice to cross them, but she was unable to. The resident was also rubbing her left hip/side.

LPN # 1 nurse's note dated 3/20/10 at 9:20 PM documented " call by CNA resident was found lying on floor in hallway by wheel chair. Resident stated she was trying to pick up diaper off floor and fell over. RN Supervisor called and exam Resident. Resident alarm in wheel chair was going off. Upon exam Resident show no pain but stated (L) (left) side hurt by hip. No swelling, no redness or broken skin, vital signs: 118/76 - 97 - 70 - 18. Doctor was called, ordered X -ray of the (L) (left) hip for AM (morning), family notified by RN (Registered Nurse) and resident put to bed and made comfortable. "

A Nurse's note dated 3/21/10 at 6:45 AM documented that the resident is post incident and " some discomfort noted, given Tylenol as requested and diaper change. "

LPN #2 Nurse's note dated 3/21/10 at 2:00 PM documented that the resident was alert and responsive with confusion. She complained of left hip pain. PRN (as needed) medication was given with relief. The left hip X-ray was not done because the resident was combative and agitated. The doctor was notified and ordered Haldol 1mg Intramuscular (IM) prior to X-ray. The portable X-ray company was notified and the RNS made aware and endorsed accordingly.

A Doctor's Progress note dated 3/21/10 at 7:00 PM documented that the resident is status post fall last night and complained of pain to the left hip. She refused X-ray. X-ray was done this afternoon. Swelling and tenderness noted to left hip, left lower extremities externally and there were positive distal pulses. The resident was referred to the Hospital Emergency Room for an urgent X-ray of the left hip, pelvis and L/S (lumbar/ sacral) spine with orthopedic evaluation.

The 3/21/10 X-ray result documented that the resident had a fracture of the left femoral neck.

RNS # 1 was interviewed on 3/26/10 at 11:15 AM. RNS # 1 stated that on 3/20/10 she went on her break at around 9:00 PM and RNS #2 covered for her. When she returned, RNS #2 left her a note stating that the resident fell and the doctor was already informed. RNS #1 went to the resident's room. When she asked the resident if she could see her leg and if she had pain, the resident told her " No, I'm okay. " RNS # 1 stated that she did not assess the resident because she refused and denied pain. She proceeded to fill out the Incident report and endorsed it to the 11:00 PM - 7:00 AM RNS. RNS # 1 stated that on 3/21/09 at approximately 7:00 AM, she went back to the 4th floor and asked the 11:00 PM - 7:00 AM LPN #2 how was the resident doing and if the X-ray was done. LPN # 2 told RNS # 1 that the resident was okay and the X-ray was not done. RNS # 1 stated that she called for a follow-up STAT (immediately) X-ray via voice mail and endorsed it to the 7:00 AM - 3:00 PM RNS.

LPN #1 was interviewed on 3/26/10 at 12:30 PM. LPN #1 stated that she approached the resident and saw that the resident was removing things from the treatment cart. LPN # 1 stated that she put her hands on the wheel chair handles and pulled the chair towards her to get the resident away from the cart and the resident went down to the floor LPN # 1 stated that she looked at the resident and asked her if she was okay. The resident told her " Yes, I'm okay. " LPN # 1 admitted that she panicked, it was the first time that something like that happened to her and nobody was around. LPN #1 stated that she did not move the resident until the RNS came per protocol. She left the resident on the floor and pushed the Medication cart to the other side trying to call somebody for help.

RNS #2 was interviewed on 3/26/10 at 5:00 PM. She stated that on 3/20/10 at approximately 9:20 PM, RNS # 1 went on break and she covered for her. RNS # 2 heard an overhead page from LPN # 1 requesting " RNS come down and see this one. " RNS # 2 stated that she immediately went to the unit and found the resident lying on her left side on the floor in front of her wheel chair. She asked the resident " do you have pain? " The resident said " No, I'm fine. " RNS # 2 stated that she did Range of Motion (ROM) exercises while the resident was on the floor. All extremities were moved 2 times each. During ROM, the resident denied pain so she instructed the CNA who found the resident and another staff member to place the resident back into wheel chair. RNS # 2 stated that she also did ROM exercises when the resident was placed back into the wheel chair. The resident denied pain but when the left leg was moved the resident stated " hurts. " RNS # 2 informed RNS #1 at 10 PM that the resident fell. She did not assess the resident any further because RNS # 1 took over from there.

The Clinical Care Coordinator (CCC) was interviewed on 3/26/10 at 10:05 AM. She stated that the incident happened on 3/20/10 at 9:20 PM and she started her investigation on 3/22/10. On 3/23/10 at 4:00 PM, she watched the surveillance tape with the Assistant Director of Nursing (ADON) and the Administrator. They observed LPN # 1 pull the resident's wheel chair causing the resident to fall. The CCC stated that it was noted in the video the RNS #2 " handling of the incident was unsatisfactory. " The CCC stated that the two RNS who investigated the incident on 3/20/10 were both suspended for one day each.

The Medical Doctor (MD) was interviewed on 4/14/10 at 1:00 PM via telephone. The MD stated that on 3/20/10 a Nursing Supervisor called him reporting that Resident #1 was found lying on the floor. He asked the RNS if the resident complained of pain, if there was tenderness and if the resident could move all limbs. The RNS told the MD that the resident was having some pain to the left hip. The MD told the RNS to get a STAT x- ray of the left hip, observes the resident and to follow protocol. On 3/21/10 at 7:00 PM the MD came to see the resident and he observed swelling to the left hip, the left leg was shorter that the right leg and the left hip was externally rotated. The MD stated that he ordered to transfer the resident to the hospital emergency room for an urgent X-ray of left hip, pelvis and lumbar/sacral spine.

RNS # 3 was interviewed on 6/2/10 at 1:10 PM via telephone. She stated that on 3/21/10 the morning after the fall, she assessed the resident and no swelling or complaints of pain were noted. She stated that LPN # 2 informed her that the resident refused the x-ray and that the MD was notified. She did not document her assessment of the resident but she should have. She further stated that she did not recall if LPN #2 informed her of the resident's complaints of pain.

LPN # 2 was interviewed on 6/2/10 at 1:30 PM via telephone. She stated that on 3/21/10 at 11:00 AM she notified the RNS # 3 that the resident complained of pain to the left hip and that the resident refused the x-ray. LPN # 2 could not recall at what time RNS #3 came to the unit to see the resident.

Resident # 5 is a 94 year old admitted to the facility on 12/17/01. Diagnoses include Pneumonia, Volume Depletion Disorder, Coronary Atherosclerosis, Hypertension, Spinal Stenosis and Osteoarthritis. The Minimum Data Set Assessment (MDS) 2.0 dated 1/16/09 identified the resident as independent in cognitive skills for daily decision making with intact short and long term memory. Resident # 5 requires extensive assistance in transfer, toilet use and bathing with one staff assist.

A Comprehensive Care Plan (CCP) initiated 9/21/08 and updated on 1/14/09 documented that the resident has a self care deficit in locomotion/transfer and required intermittent supervision for transfers and mobility. The facility's interventions added on 1/14/09 included transfers with minimal assist of one person. Interventions added on 1/20/09 included Floor Ambulation Program (FAP) equal or greater than 50 feet with rolling walker with contact guard assist (CGA) of one person two times daily.

A CCP for an Actual Fall dated 2/9/09 documented that the Nurse called the Nursing Supervisor (RNS) in response to a CNA calling for help. The Nurse observed the resident sitting on the floor in the hallway holding her head. A body assessment was done and a hematoma on the back of head was noted with a complaint of left hip pain. The MD was notified and ordered for the resident to be transferred to the hospital for evaluation.

A review of the Internal Investigation for the 2/8/09 fall documented that as per CNA # 1, she was ambulating the resident with a walker, standing close behind her with wheelchair and the resident started to fall backwards. The CNA stated that she pulled the wheelchair back and was unable to explain why.

A (LPN) note dated 2/8/09 at 2:30 PM documented " called by staff resident observed in hallway sitting on the floor. " The resident stated that she was walking with the walker and lost her balance. The resident was put back to bed and a body assessment and vital signs were done. The Nursing Supervisor (RNS) " aware, MD paged with order to transfer resident " to the hospital.

A Nurse's note dated 2/8/09 at 6:45 PM documented that the resident was admitted to the hospital with diagnosis of femur fracture.

RNS # 4 was interviewed on 12/28/09 at 10:30 AM. RNS #4 stated that she was called to the unit by LPN # 3. When she responded Resident # 1 was already in the wheel chair. RNS #4 stated that the resident fell during floor ambulation with the CNA. She stated that LPN #3 and the CNA picked up the resident from the floor without being assessed by an RN. RNS # 4 examined the resident in bed and observed a hematoma to the back of the head and the resident complained of left hip pain. RNS #4 stated that she counseled LPN # 3 not to pick up a resident status post fall if the resident complained of pain or sustained hematoma and that she must notify the RN.

The Director of Nursing (DON) was interviewed on 12/28/09 at 1:00 PM. She stated that any Licensed Nurse can assess a resident status post fall if there is no serious injury. However, if there is pain and visible injury, the LPN should call the RNS and should not pick up the resident until they are assessed by the RNS.

CNA # 1 was interviewed on 5/3/10 at 10:10 AM via telephone. She stated that on 2/8/09 the resident refused to ambulate in the hallway because it was too crowded with residents. She did the Floor Ambulation with the resident in a small spaced area close to the exit door. CNA # 1 stated that she ambulated the resident with a rolling walker and she followed behind her with the wheel chair. All of a sudden, the resident lost her balance to both legs and she was not able to catch the resident as she fell backwards. She called the Charge Nurse (LPN# 2) when the resident fell and the Charge Nurse told her and another CNA to help her to put the Resident back in the wheel chair. CNA # 1 stated that she was aware that the resident required contact guarding during floor ambulation as per the accountability record and that she should not have followed behind the resident with the wheel chair.

LPN #3 was interviewed on 5/5/10 at 9:35 AM via telephone. She stated that on 2/8/09 at approximately 2:00 PM she heard a bump/big noise while passing medications. When she checked, she saw the resident sitting on the floor in the back hallway by the exit door with a CNA. She asked another CNA to get a pillow to make the resident comfortable and she paged the RNS. LPN #3 stated that during her assessment, the resident was screaming, complaining of left hip pain but told her that she was okay and wanted to go back to her wheel chair. She instructed two CNAs to help her put the resident in the wheelchair, when the RNS came the resident was already in the wheel chair.

415.11 (c) (3) (i)