cms_GA: 2062
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2062 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2018-04-02 | 600 | E | 1 | 0 | 5W1R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and policy review the facility failed to ensure three residents (R) (R#3, R#6 and R#7) were free from physical and verbal abuse The sample was ten (10) sampled residents. Findings include: Facility Policy titled Abuse, Neglect and Prohibition revised 12/17 revealed, Upon discovery of alleged abuse, the staff member(s) involved in the incident will be immediately suspended pending investigation. If the alleged violation is verified, and involves staff member(s), corrective action will be immediately taken up to and including discharge, The State Nurse Aide Registry or licensing authority will be notified. Record Review revealed grievance/complaint report for R#3 dated 3/5/18 that indicated a complaint was made by R#3's family member that documented on 2/15/18 the complainant observed Certified Nursing Assistant (CNA) AA, pull R#3 up from the back of her pants and threw her in the bed. Additionally, the grievance indicated that on 2/28/18 an officer was called to the facility because on 2/26/18 the family member came to the facility and R#3 had a bruise and did not have a sheet or anything on her, R#3 pulled her gown and soiled undergarments off and the complainant saw the bruises. The complainant called 911 and the officers came out and took pictures. Further record review revealed R#3's Minimum Data Set ((MDS) dated [DATE] revealed the resident has severe mental impairment coded on the Brief Interview for Mental Status a score of 99. R#3's [DIAGNOSES REDACTED]. The Assessment also indicated R#3 required substantial assistance with chair to bed transfer with the helper providing more than half the effort. During an interview on 3/26/18 at 9:27 a.m. Registered Nurse (RN) DD revealed she is aware that she is supposed to report allegations of abuse to the State Agency but does not remember why she did not report the allegation of abuse reported in the grievance for R#3 dated 3/5/18 to the State Agency. During an interview on 3/20/18 at 1:53 p.m., the facility Administrator revealed with R#3, the incident/allegation of abuse should have been reported to the State Agency. With the police coming and the police report being done, it should have been reported. The nurse initially dealing with the issue should have reported it, I am almost 99% sure I told the nurse to report it, I do understand our policy wasn't followed. The CNA should have been suspended, we had the name and she should have been suspended. During an interview on 3/20/18 at 4:30 p.m., the facility Director of Nursing (DON) revealed the nurse in charge failed to report allegations of abuse and the facility told CNA AA that she could no longer work with R#3 on the morning of 3/20/18. The DON added, she and the Administrator did not know about the other two incidents with the other two residents. (R#6 and R#7) 2. During an interview on 3/19/18 at 3:45 p.m. CNA BB revealed he saw CNA AA hit R#6, she was playing with him and shoved him a couple of times a few weeks ago. During an interview on 3/20/18 at 9:13 a.m. CNA AA revealed, if R#6 is right there in the wheelchair, going for the cart or something, I will push him out of the way because he will knock the cart over. CNA stated, I just push him like gone. That happens all the time, he can reach the nurses cart. I don't remember any incident but yes, I may have pushed him some to move him. I have never been mad at him. During an interview on 3/19/18 at 5:06 p.m. CC revealed she never saw CNA AA hit R#6 but she did see her hands go up while R#6 was fussing and told her not to play with him in that manner, do not touch him. During an interview on 3/20/18 at 4:30 p.m., the facility Director of Nursing (DON) revealed the situation with R#6 was not handled correctly. Staff are expected to report any form of abuse to the Administrator or DON immediately, or another supervisor. There are appropriate ways to redirect a person without pushing, pulling or shoving. The DON further added the pushing was an unintentional form of abuse. Record review revealed no reporting of the incident mentioned above, further record review revealed R#6 BIMS score of 99, resident is moderately impaired when making decisions concerning tasks, he is independent with bed mobility, transfers, locomotion on and off the unit, eating and toileting. He requires extensive supervision with hygiene and dressing. His [DIAGNOSES REDACTED]. 99, indicating severe mental impairment. R#3's [DIAGNOSES REDACTED]. The Assessment also indicated R#3 required substantial assistance with chair to bed transfer with the helper providing more than half the effort. 3.During an interview on 3/19/18 at 3:45 p.m. CNA BB revealed he witnessed CNA AA call R#7 lazy and tell him he didn't want to do (expletive) in front of staff and other residents everyone in the dining area and Licensed Practical Nurse (LPN) CC just said she didn't want to hear her say that again. During an interview on 3/19/18 at 5:06 p.m. LPN CC revealed she did hear CNA AA: call R#7 lazy in front of other residents and told her not to do that because it is a dignity issue. During an interview on 3/20/18 at 9:13 a.m. CNA AA revealed, she heard R#7's sister called him lazy and just repeated what she said because the resident could feed himself and would not and LPN CC told her not to say that because it was demeaning to him. During an interview on 3/20/18 at 1:53 p.m., the facility Administrator revealed he does understand that the CNA calling R#7 lazy in the dining area can be considered verbal abuse. The CNA should have been written up and there should have been additional disciplinary action. During an interview on 3/20/18 at 4:30 p.m., the facility Director of Nursing (DON) revealed CNA AA should have been suspended for the lazy comment pending investigation for verbal abuse. The policy allows the facility to suspend staff pending the outcome of an investigation. Record review revealed R#7 BIMS score of 4, indicating severe mental impairment. His [DIAGNOSES REDACTED]. | 2020-09-01 |