cms_SC: 4704
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4704 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 226 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to follow their policy to complete a thorough investigation and report immediately to state agencies any allegations of abuse, neglect and misappropriation of funds. The facility failed to conduct a thorough investigation for 1 of 1 allegations of misappropriation of funds (resident #69). The facility failed to conduct an investigation and report allegations of abuse for 1 of 1 residents the facility identified a concern with (resident # 178). The facility failed to report and provide a thorough investigation of 2 of 2 random allegations of abuse reported to them by the surveyor. The findings included: Cross refer to F 224. Preventing, investigating and reporting allegations of abuse, neglect and misappropriation of funds/personal property. Resident #178 reported someone had entered their room in the middle of the night and had him/her sign a paper. The resident did not know who the person was or what was on the paper. The resident was told not to mention the letter and not to tell anyone that the resident had a visitor. The facility also received reports the person that entered the building in the middle of the night made copies of medical records. No investigation had been conducted nor were the allegations reported to the state agencies. Resident # 69 reported to the facility that a Certified Nursing Assistant (CNA) had his/her bank card and had used the card without the resident's authorization. The CNA had the resident's car as well. The facility did not have a thorough investigation of the allegations. The facility's investigation did not included an official statement from the resident. There were no interviews/statements of other resident's that may have been affected by the CNA's practice. There were no statements obtained from the staff. During the Recertification/Complaint Survey, the facility Administration was notified by the surveyor of two allegations of abuse the facility was not aware. The facility Administration stated they would do an investigation. No reports were received by the state agency of the allegations. The facility admitted Resident #211 with [DIAGNOSES REDACTED]. During an individual interview on 4/19/16 at 10:49 AM, Resident #211 stated staff were not nice to her. He/she continued by stating after asking for assistance, the nurse slammed his/her hands down on the counter and asked don't I always help you? He/she continued by stating the Administrator had been informed of the event. Record review on 4/20/16 of the nurse's notes and the social services notes did not reflect the incident. Investigation of the incident was requested on 4/19/16. A grievance form had been completed on 4/17/16 which stated the resident did not feel the nurse provided enough assistance in helping the resident go to the bathroom. Per the findings of the investigation, the nurse felt he/she was trying to help the resident maintain her independence and felt he/she was professional and thorough with the resident's activities of daily living. After the investigation, it was determined the resident did not feel comfortable with the nurse. The action taken was the nurse would not be assigned to the resident. After reviewing the grievance, the facility was asked if they were aware of the nurse allegedly slamming her hands down on the desk when the resident was speaking to him/her. The facility did not have knowledge of the incident. On 4/20/16, an initial 24-hour report was completed and sent to the State Survey Agency. The incident was described as verbal abuse as an employee was overheard yelling and cursing at Resident #211. A witness statement was obtained with a date of 4/16/16 which alleged the nurse in question had cursed at the resident. During an interview with the Administrator on 4/23/16 at 10:59 AM, he/she had no explanation as to why the date on the witness statement was 4/16/16 and no explanation why this was not reported at the time of the incident. Review of the facility policy titled Abuse Policy and Procedure revealed under Section III-A Reporting the following: Any person observing(or hearing a complaint of) mistreatment, neglect, abuse or misappropriation of resident property should immediately report it to the Administrator, Social Services Director, Director of Nursing or other department head. CFR 483.13(c) F-226 Develop/Implement Abuse/Neglect, etc Policies was identified at a scope and severity level of (L). The facility failed to follow and implement policies related to investigation, preventing and reporting of allegations of abuse for Residents #69, #178 and #211. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable on 4/28/16 at 2:05 PM. Observation, record review and interview provided evidence to the survey team prior to exit the A[NAME] had been implemented by the facility and the Immediate Jeopardy at F-226 was removed, but the citation remained at a lower scope and severity of F. The A[NAME] included the following: A[NAME]: It has been alleged in the context of the pending survey process that the Facility's response to events allegedly occurring on or around (MONTH) 17th-20th, was insufficient. In an effort to demonstrate and achieve substantial compliance with applicable and involved regulations, the Facility proposes and has initiated implementation of the following plan of correction: * Resident Security- 1. In an effort to put immediate corrective action in place, Resident #1 was asked by the Administrator to inform Facility Administration in the event there is a recurrence of uninvited or unwanted visitors entering (his/her) room (employees or otherwise). Further, the Resident was reminded of (his/her) right to speak with the Department of Health or the Ombudsman should (he/she) ever have questions or concerns, or should (he/her) require additional information on any topic affecting (his/her) Facility admission. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has conducted an investigation into the subject events which included interviews of all residents. Specifically, each resident has been asked if they have ever been visited by people they did not recognize, and where applicable, the time, dates are being investigated to determine the nature of the visit. Further, on 4/22/16, the Facility has provided each current resident with a flyer containing the phone numbers of the South [NAME]ina Department of Health and Environmental Control, and the local Ombudsman. Going forward, this same flyer will be distributed to incoming residents on admission. Additionally, the codes have been changed at each pedestrian entrance door. (4/23/16) 3. The following measures have been put in place to ensure the deficient practice will not reoccur: * A sign-in log was placed at the front desk. All visitors (which includes employees who are in the Facility for reasons other than working a scheduled shift) will be required to sign in at the front desk, and indicate their purpose in visiting the Facility. If a visitor is there to see a resident, the name and room number of the Resident must be indicated on the sign-in log. * All employees have been informed via in-service that they should not be present on Facility premises unless they are assigned to work, or have other work-related business at that time Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * The following information has been inserviced: Abuse, Neglect, Misappropriation, and timely reporting of an allegation Resident Rights, and timely reporting of any violations Door code change for security, an sensitivity of code. * All employees have been trained (4/23/16) that in the event any employee is seen entering the Facility at hours not typically worked by that employee, they are obligated to report such unusual activity to Facility management. Our two assistant ADONs, (names), have conducted the training, which was completed today (4/27/16). * Signs have been posted at or near each door leading in to the Facility, instructing all visitors to sign in at the front desk (4/25/16). * The code to all exit doors was changed on 4/21/16. All active employees, and resident responsible parties were notified of the code change. * Protection of Private Health Information 1. In an effort to put immediate corrective action in place, Resident #1 was informed by the Administrator that an employee of Compass Post-Acute Care is alleged to have collected private information about (him/her) outside the scope of (his/her) employment. Our guidance to (him/her) reflected the information we have to date and the possibility that (his/her) protected health information may have ben accessed for reasons unrelated to (his/her) treatment, payment or other healthcare purpose. 2. In an effort to identify other residents who have the potential to be affected by the same practice, the Facility has invited members of our Compliance Department to come and evaluate our existing practices. All employees have been re-educated (4/27/16) regarding their obligations under HIPAA, and all new employees (and agency if necessary) will receive the more comprehensive training upon hire via a web-based module [MEDICATION NAME] approximately 45 minutes. 3. In addition to the physical security items listed above, the following measures have been put in place to ensure the deficient practice will not reoccur: * Any time a chart is removed temporarily from the nursing station, the employee doing so must note the removal in the log created to capture this information. The employee will need to log the date, time of removal, time of return, and purpose associated with the temporary removal. * Employees who remove medical records from the Facility or who access the chart for reasons inconsistent with Federal and State Privacy Laws will be disciplined up to and including the possibility of termination. * A video surveillance system is to be installed and contractors have been contacted. The system will provide remote visualization of each door leading in to the Facility, and will also show activity in public or shared areas including but not limited to hallways, nursing stations, dining rooms, etc.). * Resident rooms will not be included in the areas capable of being viewed by the cameras. The Department should also be aware that the employee whose conduct is at issue has been suspended pending the results of our investigation. (He/she) has not worked in the Facility or had contact with any Facility resident since. We allege compliance as of this day (4/27/16). | 2019-09-01 |