Articles Posted in Falls & Fractures

A new report by the Associated Press illustrates the devastating toll of the Covid-19 pandemic on nursing home residents across the country. The tragedy is not limited to Covid-19 deaths themselves, but also to deaths from other causes that ballooned as staff dealt with Covid-19 patients. One expert cited in the report estimated that “for every two COVID-19 victims in long-term care, there is another who died prematurely of other causes.” Ultimately, they concluded, there may have been more than 40,000 more “excess deaths” in nursing homes since March, compared to the same period in previous years.

The expert, professor Stephen Kaye at the University of California, San Francisco, attributes the spike in excess deaths to staffing issues at nursing homes. By comparing death rates at nursing homes that experienced outbreaks to nursing homes that didn’t, he found that “the more the virus spread through a home, the greater the number of deaths recorded for other reasons,” which suggests that healthcare workers were “consumed” caring for Covid-19 patients—and/or contracted the illness themselves—and therefore unable to devote adequate care to residents without Covid-19. Kaye suggests this effect was compounded by longstanding staffing issues at nursing homes: “In 20 states where virus cases are now surging,” the report observes, “federal data shows nearly 1 in 4 nursing homes report staff shortages.” Continue reading

Oak Hill Rehabilitation and Nursing Care Center has received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The Ithaca nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not prevent significant medication errors. Under Section 483.25 of the Federal Code, nursing homes must ensure residents “are free of any significant medication errors.” A February 2020 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for three medications. The citation states specifically that the residents “did not receive significant medications as ordered.” A plan of correction undertaken by the facility included the administration to two residents of their missed doses, and an RN Assessment of all three residents, one of whom was already discharged.

2. The nursing home did not properly prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain a program designed to ensure residents a safe and sanitary environment via the maintenance and control of infection. A February 2019 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for one resident. The citation states specifically that the resident’s catheter bag and tubing were resting directly on the facility’s floor, in violation of health policy. It goes on to state that the facility’s washers and dryers “were not maintained according to user manual,” and that “There was no documented facility policy for the maintenance of the washers and dryers.” A plan of correction undertaken by the facility included the placement of the resident’s catheter in a labeled basin, and the required maintenance of the washers and dryers.

Cayuga Nursing and Rehabilitation Center has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $36,000 in connection to findings that it violated health code provisions concerning resident rights, accidents, quality of care, pressure ulcers, food standards, administrative practices, and more. The Ithaca 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 employ adequate infection-control procedures. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain an infection control program so as to stave off the development and transmission of disease. A June 2019 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such. The citation describes the facility’s staff’s failure to “follow proper infection control technique during a skin treatment observation,” specifically describing failures to wipe down equipment, perform hand hygiene, and use proper equipment. The equipment goes on to state that the facility did not employ proper infection control technique while administering medication to seven residents, specifically describing a nurse who did not perform hand hygiene between each resident’s medication administration. A plan of correction undertaken by the facility included the re-education of the nurse in question.

2. The nursing home did not employ adequate measures to care for pressure ulcers. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with necessary treatment and services to prevent and/or heal pressure ulcers. A December 2017 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such for one resident. The citation specifically describes a resident who was identified on admission as having a Stage II pressure ulcer, but “was not re-assessed timely and she was not provided with pressure relief interventions as planned to promote healing.” A plan of correction undertaken by the facility included the education of relevant staff and the revision of the resident’s plan of care.

Wyoming County Community Hospital Skilled Nursing Facility has received 40 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The facility has also received a total of $16,000 in fines in connection to findings that it violated health code provisions concerning accidents, quality of care, and administrative practices. The Warsaw nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent and control infection. Per Section 483.80 of the Federal Code, nursing home facilities must create and uphold an infection prevention and control program so as to help prevent the transmission of disease and infection. A February 2019 citation found that Wyoming County Community Hospital did not ensure such. The citation states specifically that the facility did not care for a resident’s pressure ulcer “using appropriate infection control technique.” It goes on to describe a nurse packing the resident’s wound with gauze when “the gauze fell out of the wounds and onto the bed.” The nurse proceeded to pick up the gauze and put it back in the wounds, then remove her soiled gloves and don clean ones. “While the LPN was trying to apply the resident’s mesh underwear the gauze pads fell out onto the bed again,” the citation states, after which the nurse picked them up and put them back in the wounds, then after the procedure removed her gloves and washed her hands. In an interview, the facility’s Registered Nurse Unit Coordinator said that “staff should wash their hands between each treatment,” and that “if the packings fall out of the wound, she would expect the nurse to start the treatment again.” In another interview, the facility’s infection prevention nurse “said that the nurses should perform hand hygiene before starting a dressing change and after removing the soiled dressings.”

2. A July 2016 citation also found that Wyoming County Community Hospital did not adequately maintain an infection control program. The citation specifically describes two resident units that “had issues involving the lack of proper transportation of soiled linens.” It goes on to describe an observation of a shower unit in which there were resident clothes, an afghan, towels, and soiled washcloths on the wet floor. According to the citation, a Certified Nursing Assistant carried the soiled linens out of the room, and they were observed making contact with her personal clothing as she “proceeded to walk down the hall to the soiled utility room and discarded the soiled items in the linen hampers.” In an interview, the facility’s Registered Nurse Educator said that “staff are taught to wear gloves and carry soiled linens away from their body and are supposed to observe universal precautions.”

Penn Yan Manor Nursing Home has received 14 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Penn Yan nursing home’s citations resulted from a total of two surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately supervise residents. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” A November 2019 citation found that Penn Yan Manor Nursing Home failed to ensure such for one resident. The citation states specifically that the resident did not receive adequate supervision to prevent her from eloping from the facility undetected and falling outside, after which her care plan “was not revised to include an actual elopement.” The citation goes on to describe the nurse turning off an alarm at the nurse’s station, after which the resident exited the facility undetected, and later being found sitting on the ground by a staffer from a “neighboring facility,” who brought her back. In an interview, the nurse in question said “she thought she was resetting the alarm at the nurses’ station when she turned it off.” A plan of correction undertaken by the facility included the re-education of staff on the nurses’ station alarm system.

2. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing homes must ensure their medication errors rates do not meet or exceed five percent. A November 2019 citation found that Penn Yan Manor Nursing Home did not ensure such for two residents. The citation states specifically that one resident’s eye drops “were administered in both eyes instead of one eye,” and the other “had a medication ordered after meals that was given over an hour after meals.” A plan of correction undertaken by the facility included the re-education of nurses on medicine administration and the disciplining of one nurse.

Diamond Hill Nursing and Rehabilitation Center has received 55 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on July 31, 2020. The facility has also received four fines totaling $22,000 over findings that it violated health code provisions regarding quality of care, staff mistreatment of residents, abuse, and more. The Troy nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not employ proper infection control protocols. Section 483.80 of the Federal Code stipulates that nursing homes must provide a safe and sanitary environment for residents through the creation and maintenance of an infection prevention and control program. A May 2018 citation found that Diamond Hill Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that the nursing home did not develop a Legionella Water Management Plan per regulations; that it failed to ensure oxygen tubing that had rested on the floor was not given to a resident to be used; that it did not ensure urinary catheter tubing was kept off the floor; and that staff members who had not received a flu vaccination properly wore face masks. A plan of correction undertaken by the facility included the review and updating of the Legionella Water Sampling and Management Plan, and the review and revision of policy concerning the use of masks by staff and volunteers who had not received the flu vaccination.

2. The nursing home did not employ adequate accident prevention measures. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with an environment as free as possible of accident hazards. A May 2018 citation found that Diamond Hill Nursing and Rehabilitation Center did not ensure such for one resident. The citation states specifically that the resident neglected to identify and report the resident’s “use of the remote control to raise her bed to the highest position as a potential risk for injury.” The citation goes on to state that the resident “was found on the floor next to her bed,” and that the bed was not in its lowest position. As a result, the resident sustained “a left distal femoral fracture and fractures of the right distal tibia (shinbone) and fibula (calf bone),” according to the citation. A plan of correction undertaken by the facility included the updating of the resident’s care plan, with the resident’s family’s agreement, to keep the remote out of the resident’s reach.

Richmond Center for Rehabilitation and Specialty Healthcare received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on July 22, 2020. It has also received four enforcement actions resulting in cumulative fines of $42,000, connected to findings that it violated health code provisions concerning resident behavior, investigations, accidents, and more. The Staten Island nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not properly mitigate the risk of infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain programs to prevent and control infection. A January 2019 citation found that Richmond Center for Rehabilitation and Specialty Healthcare did not ensure such. The citation specifically describes a respiratory therapist who performed suctioning on a resident without practicing proper hand hygiene. According to the citation, the therapist put on a pair of gloves and started suctioning the resident without first washing his hands. In an interview, the therapist “acknowledged that he didn’t wash hands prior to donning gloves and performing suctioning of the resident.” A plan of correction undertaken by the facility included the counseling and re-in-servicing of the respiratory therapist.

2. The nursing home did not take adequate measures to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with an environment as free as is possible from accident hazards. A June 2017 citation found that Richmond Center for Rehabilitation and Specialty Healthcare failed to ensure such. The citation states specifically that “a portion of the hand rail outside of the 2nd floor dining room was observed missing, exposing a portion of metal.” Another observation of a 3rd floor dining area bathroom found that “the handrail to the right side, behind the toilet seat” had a “sharp exposed metal plate.” In an interview, the facility’s Director of Maintenance said that “no one had reported any issues with the metal plate behind the toilet and that the sharp plate would be covered to prevent resident injury.”

Elderwood at Waverly suffered 19 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 17 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. It was additionally the recipient of a 2019 fine in connection to findings in a 2018 survey that it violated unspecified health code provisions. The Waverly nursing home’s citations resulted from a total of six surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not properly supervise residents to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to ensure resident environments are kept as free as possible of accident hazards, and that residents received “adequate supervision and assistance devices to prevent accidents.” A January 2019 citation found that Elderwood at Waverly failed to ensure residents received an adequate level of supervision with the use of assistance devices. The citation specifically describes a resident with “moderate cognitive impairment” who required the assistance for transfers and walking. “The resident utilized a wheelchair and walker, was not steady when moving fro a seated to standing position and for surface to surface transfers,” according to the citation, which goes on to describe an instance in which the resident was observed “self-propelling from the dining room to her room using doorways and handrails to assist” and with her feet under her wheelchair’s leg rest foot plates; it also describes another instance in which she stood from her wheelchair to move to the other side of a table in the dining room, and another in which she self-propelled with her feet under her wheelchair’s leg rests. In an interview, the facility’s Director of Therapy stated that “any resident who self-propelled in a wheelchair with their legs and feet should not have leg rests on the chair due to the risk to fall and impeding mobility.” A plan of correction undertaken by the facility included a revision of the resident’s care plan concerning the use of leg rests.

2. The nursing home did not protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to protect each resident’s right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” An October 2018 citation found that Elderwood at Waverly failed to ensure such. The citation specifically describes a resident who “was observed on video being hit by facility staff.” According to the citation, a Registered Nurse “bent to kiss the resident on her forehead” after administering medication, at which point the resident struck theRN in the face, and the RN “responded by grabbing and slapping the resident’s left arm.” A plan of correction undertaken by the facility included the termination of the RN.

The Paramount at Somers received 28 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 7, 2019. The facility was also the subject of a 2012 fine of $14,000 in connection to alleged violations of New York Code sections concerning nursing home residents’ right to be notified of their rights, rules, services, and charges; administrative practices and procedures; and nursing home facility medical directors. The Somers nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not ensure residents were provided with an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to maintain an environment as free as possible from accident hazards, with adequate supervision and assistive devices to prevent residents from sustaining accidents. An October 2018 citation found The Paramount did not provide frequent room checks and supervision of a resident who “had numerous falls in her room without injury.” The citation states that the resident’s care plan included frequent room checks as an intervention method to prevent falls, but such checks were not implemented, and the facility “did not determine if frequent checks were conducted or a potential contributory factor to the accident.”

2. The nursing home did not take adequate steps to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing home facilities must “establish and maintain an infection prevention and control program” that creates a safe and sanitary environment for residents. A February 2019 citation found that facility did not ensure staff followed proper hand hygiene so as to prevent infection. An inspector specifically observed a failure by staff to perform proper hand hygiene while feeding residents at mealtime and assisting residents with feeding. The inspector also observed a staff member change the dressing on a resident’s wound and then lift a “sterile dressing instrument package” without putting on new gloves or washing her hands after discarding the resident’s soiled wound dressing.

Cypress Garden Center for Nursing and Rehabilitation received 20 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 12, 2019. The Flushing nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide adequate supervision or assistive devices to prevent residents from falling. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments remain “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2016 citation found that Cypress Gardens did not ensure that a resident who had been identified as “High Risk” for falls received adequate supervision to prevent them. An inspector specifically found that in June 2016 the resident was observed on the floor after a fall, having “sustained abrasions to the forehead and left forearm.” According to the citation, the resident’s care plan interventions for falls included a chair alarm, but at the time he “did not have a bed or chair alarm in pace.” The citation found that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement proper measures to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to maintain and implement “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A September 2019 citation found that the nursing home failed to provide such in an instance when an eye doctor consulting at the facility “did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam.” An inspector observed the eye doctor wiping off an exam table with a paper towel and then placing his equipment bag on it while there were still “stains” on the table; the doctor then moved the table into a resident’s room, according to the citation, and performed an eye exam on the resident without performing hand hygiene beforehand, although he was observed performing hand hygiene afterward.

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