Articles Posted in Physical Abuse

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Ira Davenport Memorial Hospital suffered 28 confirmed and 1 presumed COVID-19 deaths as of January 2, 2021, according to state records. The nursing home 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 2, 2020. The Bath 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. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments are kept “as free of accident hazards as is possible” and that staff provide residents with “adequate supervision… to prevent accidents.” An April 2019 citation found that Ira Davenport Memorial Hospital failed to ensure such. The citation states specifically that one resident was not provided with sufficient protection from accidents and subsequently suffered a fall with injury. It a section describing the incident in question, the citation states that “the resident was walking in the hall, lost her balance, and fell to the floor hitting her head and sustaining a goose egg to her left forehead.” The registered nurse who documented the fall wrote that there were no fall protections in place for the resident. A plan of correction undertaken by the facility included the revision of her care plan “include the presence of safety devices, ambulation changed to assist of one due to presence of illness and 15 min checks instituted.”

2. The nursing home did not adequately protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents are guaranteed the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2018 citation found that Ira Davenport Memorial Hospital did not ensure such for one resident. The citation states specifically that a Certified Nursing Assistant hit a resident on the resident’s left thigh after the resident grabbed the CNA’s hair. According to the citation, the facility’s policies forbade abuse, and the CNA had received abuse training. A plan of correction undertaken by the facility included the termination of the CNA.

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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.

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Steuben Center for Rehabilitation and Healthcare has received 38 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 a 2018 fine of $10,000 in connection to findings in a 2017 inspection that it violated unspecified health code provisions. The Bath 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 protect residents from abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse.” A January 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for one resident. The citation states specifically that a Licensed Practical Nurse was witnessed undressing and washing the resident after the resident told the LPN to stop, then pushing the resident onto the toilet when the resident attempted to stand up. The citation also states that the LPN told another nurse at the facility “that she wanted to use the biggest needle she could find on the resident.” A plan of correction undertaken by the facility included the suspension and subsequent termination of the LPN.

2. The nursing home did not properly prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must maintain a program to prevent and control infection. A July 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for two residents. The citation states specifically that a nurse “did not properly disinfect the blood glucose testing machine (glucometer) before or after resident use.” In an interview, the nurse said “she should have wiped the glucometer down between residents” and that “she usually cleans the glucometer with bleach wipes that are located at the nurses’ station.” The facility’s Assistant Director of Nursing said in another interview that “she would expect the nurse to clean the glucometer in between residents using the approved bleach wipes.”

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Washington Center for Rehabilitation and Healthcare has received 49 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 $74,000 in fines in connection to findings that it violated health code provisions concerning infection control, accidents, medication errors, resident behavior, hydration, administration, and more. The Warsaw 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 protect residents from physical abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A January 2020 citation found that Washington Center for Rehabilitation and Healthcare failed to ensure this right for two residents. The citation specifically states that it did not ensure the two residents “were free from physical abuse related to a resident to resident altercation.” It describes an incident in which one resident attempted to pull another resident’s wheelchair “and was swinging a fist at the resident,” who in response “used his reacher and struck” the resident “twice in the face,: at which point a staffer separated the residents. A plan of correction undertaken by the facility included a rooming change for the residents, who were roommates.

2. A November 2019 citation also found that Washington Center for Rehabilitation and Healthcare did not protect residents from abuse. The citation specifically describes a Registered Nurse Supervisor assaulting a resident. According to the citation, the RNS instructed two other staffers to to hold the resident’s hands while the RNS placed medication crushed into pudding into the resident’s mouth. Per a written statement, one of those staffers said “that RNS #1 had instructed LPN #1 and CNA #1 to hold Resident #1’s hands, then put medication into his/her mouth. When RNS #1 put the medication in Resident #1’s mouth, she tipped his/her head back and put her hand in front of his/her mouth.” A plan of correction undertaken by the facility included the suspension, investigation, and termination of the RNS.

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Staten Island Care Center received 23 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. 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 effectively ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing home facilities must create and uphold a program designed to prevent and control the development and transmission of disease and infection. A June 2019 citation found that Staten Island Care Center failed to ensure such. The citation specifically describes a housekeeper who was observed exiting the room of a resident on contact precautions without wearing personal protective equipment. The housekeeper, who was “mopping the floor” of that resident’s room, was observed using the same mop to clean another resident’s room. 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 in-servicing of the housekeeper on the cleaning of isolation rooms and use of PPE.

2. The nursing home did not protect residents from physical abuse. Section 483.12 of the Federal Code provides nursing home residents with “the right to be free from abuse.” A May 2018 citation found that Staten Island Care Center did not ensure such for one resident. The citation specifically states that facility surveillance camera footage showed the resident sitting in a wheelchair a Certified Nursing Assistant “pulled the resident’s shirt from the back of the neck.” According to the citation, the resident said in an interview that they had also been struck by a staff member. While the footage did not show the resident being hit, according to the citation, a Certified Nursing Assistant said in an interview that she witnessed another CNA striking the resident in his face “but did not report it.” A plan of correction undertaken by the facility included the initiation of an abuse prevention plan.

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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.

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Rego Park Nursing Home received 22 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 deficiencies they describe include the following:

1. The nursing home did not ensure residents were free from abuse. Section 483.12 of the Federal Code stipulates that nursing home residents have a right to freedom from abuse and neglect. An August 2019 citation found that Rego Park Nursing Home failed to protect a resident from abuse. The citation specifically found that a Certified Nursing Assistant was captured on video camera footage kicking a resident twice in the facility’s dining room, “once on the left leg and once on the left leg.” The resident was subsequently seen bleeding and transported to the local hospital, where the resident received “11 sutures on the left leg and 10 sutures on the right leg.” Following the incident, the Assistant was terminated from the facility, and arrested by local police.

2. The nursing home did not take adequate steps to investigate allegations of abuse. Section 483.12 of the Federal Code requires nursing homes to respond to allegations of abuse, neglect, exploitation, or mistreatment by providing evidence that alleged violations are investigated and that the results of investigations are reported to relevant authorities. An August 2018 citation found that Rego Park Nursing Home did not provide for the thorough investigation of a resident’s injury. The citation states specifically that a resident was found “with yellow-green discoloration underneath the eyes and bridge of the nose.” An investigation of the injury, according to the citation, omitted statements or interviews from staff who had worked with the resident in the days preceding the injury. The citation states further that “The statements that were obtained did not include any information regarding the person’s interactions with the resident, and the investigation did not address that the injury was resolving at the time it was identified and reported.” The findings concluded that these deficiencies had the “potential to cause more than minimal harm.”

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Park Nursing Home received 39 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 3, 2020. The Rockaway Park nursing home’s citations resulted from a total of eight inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure residents were protected from abuse. Under Section 483.12 of the Federal Code, nursing homes must ensure their residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found Park Nursing Home did not ensure its residents remained free from abuse. The citation specifically found that “a cognitively impaired resident who displays physical aggression towards others physically assaulted more than one resident, one more than one occasion.” An inspector found that whereas the facility implemented interventions to address this resident’s conduct, these interventions “were not evaluated for their effectiveness.” A Director of Nursing stated in an interview that these interventions included separating the resident from others, close monitoring, and placing him with residents able to defend themselves; the DON said also that “these interventions were not all documented and should have been.”

2. The nursing home did not provide residents adequate supervision to prevent elopement. Section 483.25 of the Federal Code requires that nursing homes provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2018 citation found that Park Nursing Home did not adequately supervise a resident who had been “identified at risk for elopement” and who refused to wear a wander guard device. The citation goes on to state that the resident eloped the facility after climbing its back gate without staff knowledge; it notes specifically that the Registered Nursing Supervisor was not notified of the elopement until approximately three hours after it occurred, and the resident was returned after another two hours. The citation notes that the elopement was attributed in part to “a breach in security,” and the facility’s plan of correction included the termination of a security officer “who left his post.”

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Dr. Susan Smith McKinney Nursing and Rehabilitation Center received 17 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2019 fine of $4,000 in connection to findings of multiple deficiencies observed in a February 11, 2019 survey. The Brooklyn 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 ensure residents’ freedom from abuse. Under Section 483.12 of the Federal Code, nursing home residents have the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found that the nursing home did not ensure staff provided residents with services necessary to avoid “physical pain, mental anguish, or emotional distress.” The citation found specifically that one of the facility’s Certified Nursing Assistants tied a resident’s left hand to bed rails using a plastic bag, resulting in psychosocial harm for the resident, “who was totally dependent on staff for all care needs, an unable to call for assistance or help.” The citation also states that another CNA “rough handled” another resident while trying to provide care. A plan of correction undertaken by the facility included the removal of the CNAs in question.

2. The nursing home did not ensure residents’ right to freedom from physical restraints. Sections 483.10 and 483.12 of the Federal Code provides nursing home residents with the right to be “free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms.” A February 2019 citation found that facility staff unnecessarily used physical restraints to inhibit a resident’s freedom of movement. The citation specifically describes a Certified Nursing Assistant tying a resident’s hand to their bed rail with a plastic bag, stating later that “she restrained the resident because he became resistive as she tried to clean feces from his hand.” The citation notes that the resident had no orders to be restrained and that the CNA was allowed by the facility to continue providing the resident with care for two days following the incident. A plan of correction undertaken by the facility states that the CNA as well as a Registered Nurse who “did not report the incident to facility administrative staff” in a timely manner were both removed from the facility. The citation also notes that the incident resulted in “actual harm” to the resident in question.

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Saints Joachim & Anne Nursing and Rehabilitation Center received 16 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 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 a resident from abuse. Section 483.12 of the Federal Code ensures nursing home residents the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A May 2019 citation found that Saints Joachim & Anne Nursing and Rehabilitation Center did not ensure this right for one resident. The citation specifically describes a resident who was “repeatedly forcefully pushed down into the chair to prevent them from getting up and going to the bathroom.” It goes on to describe a witness stating that she observed the CNA push the resident and expressing her wish for the CNA in question not to care for her mother. The CNA “was not nice and very rough with a resident,” according to the witness’s statement, “pushing the resident to sit down.” A plan of correction undertaken by the facility included the termination of the CNA in question.

2. The nursing home did not implement adequate measures to investigate and prevent abuse. Section 483.12 of the Federal Code stipulates that while nursing homes investigate allegations of abuse, they must ensure the prevention of further abuse. A May 2019 citation found that Saints Joachim & Anne Nursing and Rehabilitation Center did not ensure further abuse while investigating the above-mentioned incident of alleged abuse; the citation also states that the allegation “was not investigated or reported to the administrator and New York State Department of Health (NYSDOH) within 5 working days.” According to the citation, when a witness reported the alleged abuse to a Registered Nurse Supervisor, that RNS did not report it to authorities or launch an investigation. The citation states additionally that following the receipt of the allegation, the facility did not immediately remove the Certified Nursing Assistant accused of abuse from their assignment. According to the citation, the CNA was in fact not removed until after the facility’s Assistant Director of Nursing launched an investigation. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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