cms_WV: 11003
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11003 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 157 | E | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to notify the attending physician and the responsible parties of eight (8) residents as having experienced mistreatment / abuse / neglect by Employee #81, as witnessed by staff. Resident identifiers: #12, #15, #30, #59, #60, #62, #61, and an unidentified resident who was no longer at the facility ("X"). Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #62, #61, and X 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed the following allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency: - Employee #81 was alleged to have audio-taped Resident #12 on her cell phone as she cursed (Reported to State survey agency on 01/25/10; date of incident was not known) - Employee #81 was alleged to have squirted water on Resident #62 (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have pushed Resident #15 quickly down the hallway in her wheelchair (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #12 to "yell and cuss" and to have given medications to this resident in an "inappropriate manner" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #61 to "yell and cuss" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have tied Resident #30's wheelchair to a side rail (Reported to state survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have put Resident #60 to bed in a "rough manner" (Reported to state survey agency on 01/27/10; date of incident was not known) - Employee #81 was alleged to be "verbally inappropriate" to various unidentified residents (Reported to state survey agency on 01/27/10; date of incident was not known) - Employee #81 was alleged to have used "inappropriate restraints" on Resident #12 (Reported to state survey agency on 01/28/10; date of incident was not known) Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated the following allegations: - Administering medications (laxatives) to an unidentified number of residents without a physician's order - Recording the voice of Resident #12 as she screamed and cursed while Employee #81 digitally removed stool from her rectum, and playing the recording for others to hear - Encouraging Residents #12 and #61 to curse - Tying Resident #30's wheelchair to a rail for staff convenience, to keep the resident from wandering -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) - In a statement dated 01/22/10 by Employee #74 (an LPN): "This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds. " In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: "Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ... " - In a statement dated 01/22/10 by Employee #50 (a CNA): "I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ... " In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: "I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61) " - In a statement dated 01/22/10 by Employee #58 (an LPN): "This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents "rowled" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them. " - In a statement dated 01/23/10 by Employee #73 (an LPN): "I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..." In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: "Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything." In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: "... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..." - In a statement dated 01/23/10 by Employee #59 (an LPN): "I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)." In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: "... Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..." - In a statement dated 01/23/10 by Employee #51 (an LPN): "I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..." In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: "... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..." In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: "... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..." - In a statement dated 01/23/10 by Employee #76 (a CNA): "I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated." - In a statement dated 01/23/10 by Employee #5 (a CNA): "I have only heard by another CNA that Nurses was getting a Resident upset." - In a statement dated 01/25/10 by Employee #75 (a CNA): "(Employee #81) has know to get people started yelling and such things as (Resident #15) in /wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react." In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: "I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..." In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: "... (Employee #81) encourages (Resident #12's first name) to cuss." - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: "... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say." -- Review of Resident #12's medical record, including nursing notes and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status (including signs / symptoms of the presence of a fecal impaction necessitating this procedure), and no nursing note entries detailing the performance of the procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 discomfort and distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. -- The facility's titled "Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation" (effective 01/09/09) stated, on Page 3: " ...The family / responsible party and attending physician shall be notified and recommendation(s) shall be followed. Documentation of notifications, recommendations and actions taken shall be documented as part of the investigation. ... With respect to notifying the physician and family of the mistreatment / abuse / neglect experienced by Residents 59, #60, #61, #62, #15, #30, and #12, the administrator reported, on the afternoon of 06/09/11, that she had contacted both the physician and the responsible parties; however, documentation to support this could not be located. . | 2014-10-01 |