A certified nursing assistant slammed a bathroom door against a Buffalo nursing home resident's face causing the individual to collapse and suffer injuries that required hospital treatment.
The aide at the Buffalo Center for Rehabilitation and Nursing did not deny the incident happened and was fired.
In a case of neglect, another resident who was prone to falling was found out of bed and on the floor in the middle of the night with injuries that included “a purple knot on the left side of the head.”
When a third resident at the Delaware Avenue nursing home participated in virtual mental health sessions, the resident’s roommate was able to listen in, creating a breach in privacy.
These three incidents at the Buffalo Center for Rehabilitation and Nursing were among numerous violations cited in a New York State Health Department inspection report that recently resulted in fines of more than $18,000 against the facility.
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On the federal Medicare.gov website that compares nursing homes for consumers, the government has taken the infrequent action of placing a red icon beside the Buffalo Center’s profile with a warning that states: “This nursing home has been cited for abuse.”
The fines and warning are the latest black marks against the nursing home.
The U.S. Centers for Medicare and Medicaid Services rates overall operations at Buffalo Center at one star, “much below average,” the lowest rating.
Last year, the Centers for Medicare and Medicaid Services fined Buffalo Center $50,869 after workers failed to follow measures aimed at preventing the spread of Covid-19.
The federal agency posted online a copy of the July 20 inspection report that resulted in the latest fines.
In the door-slamming incident, “Resident #10” was in the bathroom at about 9 p.m. Jan. 26 when the nursing assistant entered it after being told to stay out, the report stated. A fight occurred and the nursing assistant slammed the door against the resident.
In a written statement, the nursing assistant stated, “All I asked was to use the sink,” in order to get water for the care of another resident in the room. Upon entering the bathroom, “Resident #10” punched the assistant in the mouth, according to the aide's statement.
The assistant then stated, “I slammed the door in [the resident’s] face and walked out.”
Police called a nursing home supervisor after receiving a complaint of abuse. The resident was taken by ambulance to a hospital for treatment, but the inspection report did not describe what injuries were suffered.
According to nursing home documents cited in the inspection report, the nursing assistant was terminated the next day “related to abuse allegation that could not be ruled out based on staff member’s statement and resident’s diagnosis.”
Jeffrey Jacomowitz, a Buffalo Center spokesman, said that such incidents “do not reflect the care that our staff provide the residents every day.”
“Buffalo Center remains committed to ensuring the best care and services for our residents and professionalism among staff,” Jacomowitz said.
The 36-page inspection report also determined the nursing home failed to provide privacy for a resident in January and February during virtual “Tele-Health” mental health counseling sessions. The resident’s roommate, the report stated, could listen in on “personal problems” that were being discussed.
The sessions were conducted by way of a mobile device attached to a pole and the only form of privacy was a drawn curtain separating the roommates’ beds, the resident told a Health Department inspector.
Fed up with the lack of privacy, the resident refused to further participate in the virtual sessions, the report stated. A staff member, according to the report, said the resident had been offered a private room but refused to make use of it.
Jacomowitz said the staff has since been re-educated on regulations pertaining to remote “Tele-Health” sessions.
In an incident involving injuries to a resident described as prone to falling, the Health Department inspection cited failure by the staff to carry out safety precautions required in the resident’s care plan.
At 2:45 a.m. May 18, “Resident #90” was found out of bed and on the floor with bruises to the left eye and forehead, according to the report. The left side of the individual’s bed should have been placed against a wall and on the opposite side, a safety mat should have been installed on the floor.
The mat was subsequently found inside the resident’s closet, the report stated.
On July 14 and again on July 16, the report stated, ”Resident #90” was sleeping on a bed in the center of the room and “there were no floor mats in place next to the bed as per the resident’s care plan.”
“There was a breach of Resident #90’s care plan and it would be considered neglect because we forgot to put down the floor mat,” the facility’s administrator told a state inspector.
Other violations listed in the inspection report included:
- Administering antipsychotic medication to “Resident #136,” even though the individual did not display dangerous behavior to justify use of the drug. An attending physician interviewed in the report stated it was wrong to administer the medication ahead of time “to prevent an event from happening.”
- Failure to provide proper grooming and hygiene. In one instance, an inspector observed “Resident #78” with “greasy and disheveled” hair and unclipped fingernails with a “brown substance” beneath them. The inspector stated the resident “could not recall the last time” a shower was offered. A licensed practical nurse, “LPN #4,” stated the resident “tends to be combative and resistive to care.”
- Instances of nurses at shift changes failing to conduct required inventories of controlled substances, paperwork discrepancies in the amount of prescribed narcotics given to residents, and a situation where keys to a narcotics cabinet were left unattended in a medication room.
- Failure to provide residents palatable food and beverages. In interviews with three residents in a fourth-floor unit, an inspector was told meals that should be served hot were often cold. One resident described a meal that included turkey as “cold and having no taste.”
Jacomowitz, the nursing home’s spokesman, said that the facility has addressed the violations.
“A comprehensive plan of correction was submitted to the New York State Department of Health, who later resurveyed the facility and found the facility to be in compliance with no further or related incidents,” Jacomowitz said
The inspection resulted in a $10,000 fine by state Health Department and an $8,037 federal fine.