A July certification survey conducted by the Department of Health at Margaret Tietz Center for Nursing Care, a Queens nursing home, suggests that the facility did not properly investigate signs of potential physical abuse of its residents. The inspection found evidence of potential abuse in three out of ten residents who the facility had been reviewing for potential unnecessary medications.
The three residents had similar bruises to their arms. The first resident was observed with a black and blue on the inside of upper arm; the second had a hematoma of both the forearm and hand; and the third was noted to have a swollen and painful wrist. In each of the scenarios listed above, additional statements regarding the injuries were obtained from the care staff with respect to how they may have occurred.
When injuries such as these occur, the nursing home must take steps to investigate the situation completely. Additionally, when there is an incident of potential or alleged abuse, the facility must prevent additional abuse while in the midst of this investigation. After the investigation is concluded, the facility must report the results to appropriate authorities, including the nursing home administrator and officials mandated by state law.
At Margaret Tietz, reporting of these incidents seems to have been precluded by the fact that a thorough investigation was not undertaken. Even the seemingly obvious step of obtaining a statement from the direct caregivers was not taken. Although the incidents involving these residents did not rise to the level of “actual harm” as defined by the Department of Health (despite the bruising evident on the residents), the potential for more than minimal harm was present. Without the results of an investigation at the time of the incidents, it is difficult to determine whether these occurrences were actual abuse or simply accidents. Avoiding this ambiguity is one reason that the regulation was enacted. Unfortunately Margaret Tietz did not follow this regulation in the cases of these residents.
The certification survey can be read on the Department of Health website.