Fordham Nursing and Rehabilitation Center: Pressure Ulcer Citation

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Fordham Nursing Home and Rehabilitation Center has received a total of 15 citations since 2017 for violating public health code on more than one occasion.

Fordham Nursing and Rehabilitation Center received 15 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Bronx nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes must ensure residents receive necessary care and services to prevent the development of pressure ulcers. A December 2019 citation found that Fordham Nursing and Rehabilitation Center failed to ensure such. The citation specifically describes a resident who was “observed on multiple occasions without heel booties or diabetic shoes,” devices meant to prevent pressure ulcers, as ordered by the physician. In an interview, a Certified Nursing Assistant said that “it is not a regular occurrence for the resident to be without her heel booties.” In another interview, a Registered Nurse said she was unable to find the resident’s diabetic shoes in the resident’s room. A plan of correction undertaken by the facility included the application of the shoes to the resident and the location of the heel booties, as well as a notation on the resident’s care plan that “the blue heel booties were to be worn at all times when the resident is in bed and diabetic shoes are to be worn when the resident is out of bed.”

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The citations were issued for reasons such as, the nursing home failing to provide proper care to residents with pressure ulcers, they did not follow protocol for preventing and controlling the spread of infection, and the nursing home did not provide overall acceptable care to its residents.

2. The nursing home did not provide adequate infection control measures. Section 483.80 of the Federal Code stipulates that nursing homes must create and uphold an infection prevention and control program in order to keep residents safe from diseases and infections. A December 2019 citation found that Fordham Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that a the oxygen tubing from a resident’s oxygen concentrator was observed on the floor in contravention of facility policy. In an interview, a registered nurse acknowledged that the tubing was on the floor and stated that it should not be, and further that facility staff “should make sure the excess tubing is attached to the side of the bed and not touching the floor.” In a separate interview, the facility’s Director of Nursing affirmed that “problem. On 12/12/19 at 12:09 PM, the Director of Nursing,” adding that the facility’s nursing staff “did not follow the protocol to prevent the oxygen tubing from touching the floor.” A plan of correction undertaken by the facility included the re-education of nursing staff.

3. The nursing home did not ensure an adequate quality of care. Section 483.25 of the Federal Code stipulates that nursing homes must ensure all residents “receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices.” A December 2019 citation found that Fordham Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that facility staff “did not identify and address a resident’s abrasions/injuries during skin assessments.” It goes on to describe a surveyor’s observation of scabs on a resident’s forearms which the resident attributed to a fall, but which were not documented on the resident’s records. In an interview, a Certified Nursing Assistant said that she had not noticed the resident’s scabs. In a separate interview, a Registered Nurse said he had not observed the scabs on the forearms and they had not been reported to him. A plan of correction undertaken by the facility included the re-education of nursing staff “on proper skin checks and accurate documentation of the skin checks.”

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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