Regal Heights Rehabilitation and Health Care Center

Based on interviews and record review during an abbreviated survey, the facility did not ensure the that an allegation of abuse of a resident was immediately reported to the Department of Health (DOH) in accordance with State Law through established procedures. The facility also did not ensure that residents were protected from further potential abuse while the investigation of an allegation of abuse was in progress. This was evidenced in 1 of 4 (Resident is # 1). Specifically, an allegation of abuse made by a resident with an observed physical injury was not reported to the DOH immediately. Additionally the facility did not remove the accused Certified Nurse Aide (CNA #1) from duty to prevent further potential abuse while the investigation was in progress.

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

Complaint # NY00085132

The finding is:

Resident # 1 is a 92 year old male admitted to the facility on 3/11/09. Her diagnoses include General Pain, Benign Prostate Hypertrophy, Hypertension, Osteoporosis and Depression. The Minimum Data Set 2.0 Assessment dated 2/27/2010 identified the resident with impaired short and long term memory and moderately impaired cognitive skills for daily decision making. He requires limited assistance of 1 staff in Activities of Daily Living (ADL) and personal hygiene.

Comprehensive Care Plan (CCP) for Mood Indicators dated 4/19/10 documented that the resident experienced physically abusive behavior from a staff member. He is at risk for emotional distress. The facility interventions include encourage resident to express feelings and provide emotional support, encourage participation in activity programs and socialization with peers, observe for any changes in mood and behavior and report to the Physician (MD).

CCP for Alteration in skin integrity due to ecchymosis dated 4/20/10 documented facility interventions including monitor skin integrity every shift, gentle handling at all times, extensive assistance with two staff at all times for transfer, provide good skin care, observe improvement/deterioration of skin condition and notify MD.

Accident /Incident Report dated 4/18/10 documented that while the Registered Nursing Supervisor (RNS) was making rounds she heard the resident complaining to the Charge Nurse that CNA # 1 hit his left forearm. The RNS observed 2 centimeters (cm) by 3 centimeters discoloration on resident's left forearm. CNA # 1 was re-assigned to other residents.

A review of the Investigation Summary by the Director of Nursing (DON) dated 4/23/10 documented that the facility was not able to rule out abuse, neglect and mistreatment and reported to the Department of Health. The Plan of Action included immediately assigning the resident to another CNA. Emotional support was provided and the accused CNA was terminated. The Plan of Care was changed to extensive assist of 2 at all times.

A review of the written statement by the Social Worker (SW) dated 4/19/10 documented that the resident was interviewed with a Spanish speaking interpreter. The resident stated that in the early hours of 4/19/10 at approximately 1:00AM, a CNA came to his room and requested him in English to do something but he could not understand. The CNA was very persistent and he finally understood that she was trying to stand him up to dress him. The resident did not want to get out of bed and refused to get up. He stated that the CNA roughly grabbed his arm to pull him up out of bed, but the resident insisted on remaining in bed. The SW observed a red colored bruise on resident's left forearm approximately the size of a thumb during the interview.

CNA #1's Personnel file included a letter dated 4/26/10 informing CNA #1 that she was terminated effective immediately.

The undated facility policies and procedures on Abuse Reporting revealed Public Health Law 2803-D requires that reports of physical abuse, mistreatment, or neglect must be made immediately by telephone to the Department of Health and followed within 48 hours in writing. Such reporting involves situations when there is reasonable cause to believe that physical abuse, mistreatment or neglect has occurred. Reasonable cause shall mean that upon review of the circumstances, there is sufficient evidence for a prudent person to believe that physical abuse, mistreatment or neglect has occurred.

A telephone interview was conducted with the Registered Nurse Supervisor (RNS) on 5/2/11 at 1:30PM. She stated that she was notified by the Licensed Practical Nurse (LPN) regarding discoloration on resident's arm. The RNS stated that she and the LPN assessed the resident and noted he had fragile skin with a 2 cm by 3 cm discoloration to left forearm. The resident told her not to send CNA #1 to him because she hit him. RNS stated that the resident was re-assigned to another CNA. She stated that CNA # 1 was removed from the assignment and was re-assigned to other residents on the unit. She stated that per protocol if a resident alleged to be abused by the staff, the staff must be removed from the assignment until further investigation and re-assigned to other residents on the unit under the supervision of the Charge Nurse. The RNS stated that an A/I Report will be initiated and the DON is notified immediately. She stated that she did not notify the DON because it was 1:00AM when the incident was discovered. She endorsed it to the next shift.

A telephone interview was conducted with the DON on 5/5/11 at 1:55PM. She stated that per facility policies and procedures, in case of alleged resident abuse by staff the resident is re-assigned to another CNA. The accused CNA will be re-assigned to other residents on the unit until the investigation is completed. DON stated that the incident happened on 4/18/10 and on 4/19/10 she started the investigation. When she completed the investigation on 4/23/10 she reported it to the Department of Health (DOH).

415.4(b)(1)(ii)