Northern Riverview Health Care Center in Haverstraw, NY was cited in a Department of Health Deficiency Survey dated May 11, 2011. The DOH cited the facility for numerous violations, including failing to ensure that the facility was free of accident hazards, and failure to develop and implement written policies and procedures that prohibit mistreatment and/or neglect.
The Statement of Deficiencies documented incidents involving falls of five residents, with the falls resulting in actual harm to each. In one such incident, a resident was admitted with diagnoses including dementia and ataxia (unsteady gait). The care plan in place for this resident stated that an alarm was to be in use on his wheelchair at all times when the resident was out of bed. Despite this, the resident was discovered on the floor on the evening of February 20th, and it was discovered that an monitoring device was not in place, contrary to care plan specifications. Subsequent to the fall, the facility did not conduct a complete investigation. Additionally, no new interventions were put in place to prevent a repeat incident. As a result, the resident suffered another fall on April 20th while in the dining room, after which the assistant director of nursing stated that, again, a wheelchair monitor was not in place.
Nursing home facilities must ensure that residents receive proper supervision and assistive devices to prevent accidents. Such steps clearly were not taken in the case of this resident. After the initial fall, the facility should have ensured, at the very least, that the original care plan was followed. Despite the actual notice provided of his risk for falls after the first incident, no steps were taken to prevent additional accidents.
As stated above, the facility was also cited for failure to prevent abuse or neglect. This failure was evident for six residents out of a sample of 17. Among the indignities suffered by these residents were: corporal punishment that went without investigation (slaps about the face and head administered by the resident's son; a bruise of unknown origin to a resident's hip (this too was not investigated); and failure to implement proper alarm interventions for a resident known to be a fall risk.
A facility implements a care plan because the staff recognizes a risk of harm or injury due to the patient's physical or mental state. The plan is meant to limit further injury, or help to heal a current condition. The care plan has no effect if it is not implemented, however. In many of the incidents documented in the DOH survey, Northern Riverview recognized a risk, but failed to follow through on its own directives to minimize the risk. These failures resulted in the accidents and injuries above. The full reports, including additional citations and incidents, can be found here.