A March, 2014 Certification Survey conducted by the Department of Health at Queens Nassau Rehabilitation and Nursing Center found that the facility failed to remain free of accident hazards. This failure resulted in actual harm for a resident of the facility.
The New York Administrative Code dictates that New York nursing homes must ensure that the resident environment remains as free of accident hazards as possible, and that each resident is adequately supervised to prevent accidents. The Department's findings at Queens Nassau centered on a resident who was admitted to the facility with several diagnoses that would affect his ability to make his own determinations regarding his well-being. The resident, among other factors, had a seizure disorder, Stage IV pressure ulcer of the hip, and dementia. Queens Nassau recognized that the resident's behavior placed him at risk for physical injury, and that he was entirely dependent on the staff of the nursing home for almost all activities of daily living.
In late October, 2013, a CNA on staff at the home entered found the resident's leg stuck in a gap between his bed and the side rail that the facility had implemented. Several days later, after showering the resident, staff noticed swelling and tenderness to the man's right thigh. He was taken to the hospital and examined. Following an x-ray, it was discovered that the man had suffered an Acute Comminuted Spiral Fracture of the Midshaft right Femur (a broken leg).
As is the case in most, if not all of these DOH surveys, investigators interviewed numerous relevant parties at the facility to determine the circumstances surrounding the resident's injury. The CNA who had been on duty on the night that the resident broke his leg told investigators that she remembered the specific incident, but that it was not out of the ordinary for that particular resident to become stuck in the side rail. Other staff members reiterated that the resident was very active while in bed, often thrashing about and toying with the side rails.
From his diagnoses, it would appear that this resident was an accident risk, particularly due to his restlessness in bed. It is the duty of the facility to ensure that such residents' environments remain as free of accident hazards as possible. It would also appear that the nursing home failed in that regard with respect to this patient.
The full DOH report can be found here.