| 100 |
ST JOHNSBURY HEALTH & REHAB |
475019 |
1248 HOSPITAL DRIVE |
SAINT JOHNSBURY |
VT |
5819 |
2019-01-03 |
600 |
E |
1 |
0 |
Z54211 |
> Based on observation, record review and staff interview, the facility failed to ensure that residents were free from abuse for 2 of 5 residents ( Residents #3, #5). Findings include: Per record review, Resident #3 was admitted at the same time as their spouse (Resident #4) in (MONTH) (YEAR), and were sharing a room. Toward the end of October, there arose a concern about safety of the couple rooming together. Resident #3 has progressing dementia and began to not recognize their spouse and expressed fear and anxiety that there was a stranger in the room. Resident # 3 was moved to another room on the unit shared with Resident #5. 1. On 11/1/18, the facility reported an incident where Resident #4 went to the spouse's new room, and was yelling to try and wake them kicking their feet. Resident #4 was physically banging the walker into and running over their feet to rouse them. Staff intervened and Resident # 4 left the room. This was reported to the state agency as required. 2. On 12/4/18, the facility reported an incident that the married residents were in the hallway, and Resident #3 stated that they wanted to go back to their room. Resident #4 grabbed the spouse's arm and kicked the walker, pulling Resident #3 toward him/her. Staff intervened and brought Resident #3 to their room. Resident #4 followed them to the room and sat on the bed, but then was attempting to move the recliner that Resident #3 was sitting in and shook their walker and yelled at the spouse. Staff directed Resident #4 out of the room. 3. On 12/19/18, per review of documentation as well as a telephone interview with now discharged Resident #5 (the roommate of Resident #3), they had reported to staff that between 2:00 PM and 8:00 PM that day that Resident #4 had repeatedly entered the room and yelled at their spouse to wake up. After supper, Resident #4 entered the room, was yelling profanities and rummaging through the belongings of both residents. Resident #4 was attempting to change the spouse's clothing, took away a drink from them, and continued to yell. Resident #5 activated the call bell and told Resident #4 to stop. Resident #4 then slammed the room door and continued to yell and act angry toward their spouse. Resident #5 stated that they yelled for help as well, but that it was at least 15- 20 minutes before staff came to the room to intervene. Resident #5 stated that they were afraid for themselves, but even more for Resident #3 who was the focus of the aggression. Resident #5 was moved to another room after this incident, however they stated that they did not really want to leave as they wanted to protect Resident #3 from their spouse. Resident #5 said that they were very upset and afraid of Resident #4, but needed to move out as they were trying to get well and go home. Per review of the incident report, this was not reported to administration until the following day. (refer to citation at F609). 4. During this onsite investigation on 1/3/19, a 4th incident was reported that occurred on 12/29/18. Per the facility report, Resident #4 was in Resident #3's room, and staff heard yelling coming from the room. Per staff witnesses, Resident #4 was yelling, That's it, I never want to see you again, I'm leaving. The staff witnessed Resident #4 shaking a fist at Resident #3. When the staff told the resident that it wasn't nice to speak to their spouse that way, Resident #4 stated that they could treat their spouse any way they wanted to. Staff positioned themselves between the two residents, and Resident #4 was pushing them to try to get to Resident #3. Staff were able to get Resident #4 out of the room, and Resident #3 then said to the staff I hope s/he did not hurt you, and was crying and appeared to be afraid. After they directed Resident#4 out of the spouse's room, they were going into other resident's rooms, yelling and saying to another resident that I am leaving, this is goodbye. The nurse ended up calling the police, and Resident #4 was escorted by them and EMS to the local emergency room , and returned later that day. Per interview on 1/3/19 at 11:05 AM, the Director of Nursing confirmed that these four incidents had occurred, and that Resident #4 had not been supervised closely enough to prevent them. |
2020-09-01 |