Beach Terrace Care Center Cited for Failing to Assess Bedsore

Beach Terrace Care Center received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Long Beach nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not take adequate measures to care for residents’ bedsores/pressure ulcers. Section 483.25 of the Federal Code stipulates that nursing home facilities must ensure residents receive the necessary care and services to promote the healing of pressure ulcers and bedsores. A May 2019 citation found that Beach Terrace Care Center did not comply with this section. An inspector found specifically that the nursing home “did not perform a timely assessment when a resident’s skin condition changed.” The resident in question had an open blister on their left heel, however, the facility had no documented evidence that this blister was assessed until two days after it was identified. According to this citation, although a Skin Assessment Sheet was filled out to inform the facility’s Wound Care Nurse, no note was written in the resident’s chart at the time it was identified. The citation states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the education of facility nursing staff on new procedures for documenting skin impairments.

2. The nursing home did not implement adequate infection control and prevention procedures. Section 483.80 of the Federal Code states that nursing home facilities must “establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” A May 2019 citation found that Beach Terrace Care Center did not ensure the maintenance of such an infection prevention control program. An inspector specifically observed a Licensed Practical Nurse, while caring for a resident’s wound, placing scissors beside a sink before washing her hands, then using those scissors to cut a segment of material to pack the wound; during the same observation, according to the citation, the LPN “did not wash her hands and don clean gloves after irrigating the wound and cleansing the peri-wound area.” In an interview, the LPN states that “she thought she had rinsed the scissors” and that “she should have washed her hands and changed her gloves after she cleansed the wound.”

3. The nursing home did not implement adequate measures to investigate allegations of misconduct. Under Section 483.12 of the Federal Code, nursing homes must thoroughly investigate “allegations of abuse, neglect, exploitation, or mistreatment” and provide evidence of those investigations. A May 2019 citation found that Beach Terrace Care Center did not ensure the thorough investigation of a resident’s fall. The citation states specifically that the resident fell “while being toileted in the tub room,” and that an accident/incident report “documented an inaccuracy regarding the resident’s transfer status and documented that two Certified Nursing Assistants were present, but only one was interviewed.” In an interview, the facility’s Registered Nurse Risk Manager stated that she did not interview the second person because they “did not witness the fall.” In a separate interview, the facility’s Director of Nursing Services stated that “at the time of the fall… the resident required an assist of one staff member for toileting, the A/I report was in error, and that the investigation was confusing.” The citation affirms separately that the accident/incident report “was erroneous.”

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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