Articles Posted in Falls & Fractures

Elderwood at Cheektowaga suffered 18 confirmed COVID-19 deaths as of January 23, 2021, according to state records. The facility has also received 27 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 23, 2020. The Cheektowaga 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 adequately prevent and control infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain an infection 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 November 2019 citation found that Elderwood at Cheektowaga failed to ensure such. The citation states specifically that in one resident unit, dirty bed linens “were placed directly on the floor without a protective barrier,” and that in another unit, oxygen tubing “was observed directly on the floor during multiple observations,” all in contravention of facility policy. A plan of correction undertaken by the facility included the discarding of the tubing and the re-education of the staff member who placed dirty linens on the floor.

2. The nursing home did not sufficiently prevent medication errors. Under Section 483.25 of the Federal Code, nursing homes must keep their residents “free of any significant medication errors.” A January 2019 citation found that Elderwood at Cheektowaga failed to ensure such. The citation states specifically that one resident’s medications “were not ordered in accordance with discharge medications specified on the hospital discharge summary.” The resident according received incorrect dosages of certain medications, and didn’t receive other medications at all. A plan of correction undertaken by the facility included an audit and reconciliation of the medical records.

Newfane Rehab & Health Care Center suffered 21 confirmed and 7 suspected COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Newfane nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from accidents. Under Section 483.25 of the Federal Code, nursing homes must provide every resident with “adequate supervision and assistance devices to prevent accidents.” A September 2019 citation found that Newfane Rehab & Health Care Center failed to ensure such. The citation states specifically that a resident who was care-planned to receive check-ups every 15 minutes and one-to-one supervision when off-unit was “observed wandering off the unit with no 1:1 staff or 15-minute check.” A plan of correction undertaken by the facility included the updating of the resident’s care plan and a monthly review of weekly wander-guard system summaries.

2. An August 2018 citation also found that Newfane Rehab & Health Care Center failed to adequately comply with accident hazard protocols. The citation states specifically that three resident care units “had issues with water temperatures exceeding 120 degrees Fahrenheit… in resident rooms and care areas.” The citation goes on to state that a resident who smokes had not received a smoking assessment, and that fall prevention interventions were not executed as plans for another resident. A plan of correction undertaken by the facility included the adjustment of a water mixing valve.

Elderwood at Lockport received 31 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 8, 2021. The facility also received a fine of $10,000 in February 2020 in connection to violations of unspecified health code provisions. The Lockport 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 steps to prevent accidents. Section 483.25 of the Federal Code requires nursing homes to keep resident environments as free as possible of accident hazards and to provide residents with adequate supervision to prevent accidents. An October 2019 citation found that Elderwood at Lockport failed to ensure such. The citation states specifically that one resident who was documented for one-to-one supervision “was left unattended in a common area,” and subsequently sustained a fall and a redacted medical injury. In an interview, the facility’s administrator said the resident was left unattended in a chair because they were sleeping, and their wasn’t any violation of the resident’s care plan. A plan of correction undertaken by the facility included a review of guidelines for one-to-one supervision of residents.

2. The nursing home did not take proper infection prevention measures. Under Section 483.65 of the Federal Code, nursing homes must establish and maintain an infection prevention and control program that helps mitigate the transmission of disease. A November 2016 citation found that Elderwood at Lockport The citation states specifically that two units “had issues that involved the lack of proper disinfection of a blood glucose monitor between resident use,” as well as with unlabeled and improperly stored resident items, and with medication being administered after staffers handled it without wearing gloves. The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the counseling of relevant staff.

Corning Center for Rehabilitation and Healthcare suffered 28 confirmed COVID-19 deaths as of January 2, 2021, according to state records. The facility has also received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 2, 2020. The Corning 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 adequately protect residents from accident hazards. Under Section 483.25 of the Federal Code, nursing home residents are required to be provided with an environment that is “as free of accident hazards as is possible.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such when it served sliced turkey to a resident “who was on a mechanical soft diet with ground meats.” In an interview, one of the facility’s Licensed Practical Nurses stated that “according to the tray ticket, the resident should have received ground turkey, not sliced.” The facility’s Director of Food Services stated in an interview that “someone on the tray line must have made a mistake.” A plan of correction undertaken by the facility included the re-education of dietary staff.

2. The nursing home did not implement adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities must “establish and maintain an infection prevention and control program designed to… help prevent the development and transmission of communicable diseases and infections.” A March 2018 citation found that Corning Center for Rehabilitation and Healthcare failed to ensure such. The citation states specifically that in connection to one resident, “there was improper incontinence care and lack of glove changing and handwashing,” and that shower stretchers used by the facility for several residents “were not clean.” A plan of correction undertaken by the facility included the cleaning of shower stretchers and the re-education of the Certified Nursing Assistant who failed to provide proper incontinent care.

The Riverside suffered 48 confirmed and 17 presumed COVID-19 deaths as of December 26, 2020, according to state records. The nursing home has also received 53 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on December 26, 2020. The New York 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 protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have a right to freedom from abuse and neglect. A June 2020 citation found that The Riverside failed to ensure such. The citation states specifically that a resident who had “dementia and a history of physical aggression” participated in four altercations with other residents after the facility transferred her to a new unit. According to the citation, the facility did not put interventions in place to address this resident’s behavior and to protect other residents in the unit. It goes on to state that one altercation resulted in a laceration to the crown of another resident’s head; a subsequent altercation resulted in the aggressor’s transfer to the hospital for evaluation. A plan of correction undertaken by the facility included the review and revision of her care plan.

2. The nursing home did not provide adequate treatment for dementia. Section 483.40 of the Federal Code requires that nursing homes provide residents suffering from dementia with “appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.” A June 2020 citation found that The Riverside failed to provide such. The citation states specifically that the facility did not take individualized interventions in response to a resident’s “increasing dementia-related behaviors that occurred after a room change,” specifically, the resident’s instigation of physical altercations with other residents, including hitting one over the head with a footrest. A plan of correction undertaken by the facility included the creation of a person-centered care plan for the resident.

A new report by the Long Term Care Community Coalition highlights “no harm” deficiencies in nursing home facilities.  “No Harm” deficiencies are citations that find a nursing home violated health code provisions in a manner that did not cause residents harm. The LTCCC argues that many such citations in fact reflect harm done to nursing home residents, and more broadly reflect systemic failures in elder care facilities. But since the citations rarely if ever result in financial penalties, the LTCCC suggests, nursing homes have no incentive to address these systemic deficiencies. The report specifically discusses citations at nursing homes in four states: Continue reading

Harlem Center for Nursing and Rehabilitation suffered 3 confirmed and 29 presumed COVID-19 deaths as of December 4, 2020, according to state records. The nursing home has also received 33 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on December 4, 2020. In May 2020, it received a fine of $24,000 in connection to unspecified findings of “multiple” health code violations. The Harlem 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 adequately establish and implement infection-control measures. Under Section 483.80 of the Federal Code, nursing homes must develop a program to prevent and control infection in a manner that provides residents a comfortable and sanitary environment. A May 2020 citation found that Harlem Center for Nursing and Rehabilitation failed to do so. The citation states specifically that facility staff were observed “not doffing Personal Protective Equipment (PPE) appropriately as they left resident rooms”; that a resident admitted with a recommendation that they be placed on contact isolation with put in a room with a resident who was not on contact isolation; that residents were seen gathering in the facility’s common areas, where staff did not encourage them to socially distance; and that a resident who had been placed on contact isolation and droplet precautions was seen “eating lunch with other residents in the dayroom without maintaining social distance.” A plan of correction undertaken by the facility included the in-servicing of relevant staff.

2. The nursing home did not provide an environment adequately free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities must ensure their residents’ right to an environment as free as possible from accident hazards, and in which every resident receives supervision and assistive devices adequate to prevent accidents. A February 2020 citation found that Harlem Center for Nursing and Rehabilitation failed to ensure such. The citation states specifically that “an oversized television was positioned on a slant, on top of a smaller dresser in a resident’s room,” and that after another resident sustained a fall, the incident was not assessed “to determine if updates were needed to the plan of care to prevent further falls.” A plan of correction taken by the facility included the mounting of the TV to the wall, and the review of the fall and updating of the resident’s plan of care.

Menorah Home & Hospital for Aged & Infirm suffered 15 confirmed COVID-19 and 48 presumed COVID-19 deaths as of November 23, 2020, according to state records. The nursing home has also received nine citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on November 24, 2020. The Brooklyn 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 protect residents from accident hazards. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents an environment as free as possible from accident hazards, and ensure that every resident receives supervision to prevent accidents. A March 2018 citation found that Menorah Home & Hospital for Aged & Infirm failed to ensure such. The citation states specifically that despite documentation for a resident to receive assistance from two persons and a mechanical lift for transfers, a Certified Nursing Assistant used a mechanical lift by herself to provide personal hygiene to the resident, resulting in the resident “sliding down and kneeling on the foot rest of the lift” and sustaining an injury to their tibia. In an interview, the CNA said that although the resident did not have “visible injuries to her legs,” she “did complain of pain.” In a separate interview, the facility’s Director of Nursing said “she believed it was poor judgment” that led to the CNA deciding to perform the care with the left on her own, without the assistance of a second person. A plan of correction undertaken by the facility included the in-servicing of nursing staff on the use of mechanical lifts. Continue reading

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.

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