cms_WV: 165
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 165 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 223 | E | 1 | 0 | HCKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of reported allegations, resident interview, staff interview, family interview, staffing records, policy review, and personnel record review; the facility failed to protect residents after an allegation of abuse for one (1) of five (5) allegations reviewed. This practice affected one (1) resident but had the potential to affect more than a limited number of residents. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., had verbalized the facility completed annual training in-services, and had one scheduled for Wednesday, 06/21/17, related to abuse and neglect. The nurse said the LPN's role was to tell the director of nursing (DON) and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. LPN #66 said if the alleged perpetrator was an employee, the person would not be allowed to work with the involved resident. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked day shift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The NA said the resident asked what time dinner was served and was told about 5:30 p.m. NA#79 stated Resident #1 asked to be put back to bed because it was only 4:00 p.m. The nurse aide alleged NA#22 told the resident they were not playing these f-----g games and don't (do not) care what your daughter says. You are not being babied. NA#79 verbalized she notified LPN #63, who was passing medications. The LPN then ensured Resident #1 was placed back in bed. NA #79 verbalized during the interview, that she went back into the room and apologized for what had happened. The nurse aide said Resident #1 did not exhibit behaviors, was very sweet person. The NA said the resident's routine was to toilet and lay down. The resident would get up fifteen (15) minutes before meals. The NA voiced she thought the family member had talked to the facility about it. The Kardex report noted Resident #1 required assistance of two (2) persons for all transfers. The care plan indicated the resident required extensive assistance (weight bearing assistance) from staff for toileting. The care plan also indicated Resident #1 was at risk for chronic pain related to the [DIAGNOSES REDACTED]. The interventions section noted the resident was able to call for assistance when in pain, ask for medication, and tell staff how much pain was experienced. Resident #1, interviewed on 06/20/17 at about 12:30 p.m. ,was in bed, lying on left side, awake and alert. The resident verbalized that staff sometimes puts her down too hard when putting her back in bed. Resident #1 said when she had a concern she told her daughter and the daughter talked to the facility. Family Member (FM) #1, interviewed at 12:48 p.m., verbalized she had not made a formal complaint because her mother was confused as to dates and times, FM #1 said the resident told someone said, Well, that was totally unnecessary to another staff person when performing care. She said she informed RN#73 last week about Resident #1's concerns, but did not file a formal complaint because she did not know if it was true. The minimum data set (MDS) with an assessment reference date (ARD) of 04/28/17 indicated Resident #1 had a brief interview for mental status (BIMS) score of 08 which indicated moderate cognitive impairment. During another interview with the assistant administrator, at 1:10 p.m., she voiced the LPN started the investigative process, filled out forms, notified the charge nurse called the social worker so there was no lag time. The administrator verbalized that she, the director of nursing, and the social worker were out of the building last week. When asked who was in charge, she said Administrator #10, whatever charge nurse, and RN #71. RN #71, interviewed at 1:17 p.m., voiced FM #1 had spoken to her on Monday (06/19/17) about an incident that happened concerning one of the aides, but did not know whether or not it was truthful. The nurse said the FM did not say what happened. The RN voiced everything was brought to the attention of the DON on Monday morning, around 11:00 a.m., but she already knew about it. The DON, entered the office shared with RN #71 at 1:18 p.m. she said NA #79 told her yesterday morning (06/19/17) , and reported the NA thought she had told the med (medication) cart nurse. The DON said it was still being investigated. The abuse, neglect and exploitation policy, with an implementation date of 11/15/16, was reviewed on 06/20/17 at 11:47 a.m. The policy defined verbal abuse as follows: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The definition of abuse was noted as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Policy number eight (8) noted the facility would make efforts to protect all residents after alleged abuse, neglect, .Examples of ways to protect the residents included h.) time off for nursing staff and increased supervision of staff and/or residents. -Number nine (9) required the nurse respond to the needs of the resident and protect them from further incident, -notify the DON and administrator, -initiate an investigation immediately and call the social worker and administrator to assist, -notify the attending physician, resident's family/legal representative and medical director -Suspend the accused employee pending completion of the investigation. Remove the employee from the resident care areas immediately . The schedule, reviewed on 06/20/17 at 12:30 p.m., indicated NA #22 worked on 06/14/17, 06/15/17, 06/16/17 and 06/19/17 on the 3:00 - 11:00 shift. The time card indicated the nurse aide worked: 06/14/17 from 2:57 p.m. to 11:23 p.m. 06/15/17 from 2:57 p.m. to 11:23 p.m. 06/16/17 from 2:57 p.m. to 11:23 p.m. and 06/19/17 from 2:59 p.m. to 6:00 p.m. Assignment sheets noted NA #22 provided care to residents as follows: 06/14/17: Resident #1, #4, #5, #15, #27, #30, #32, #37, #52, #53 and #54 06/15/17: Resident #1, #3, #6, #7, #11, #17, #20, #25, #31, #34, #39, #48, #49 and #56 (discharged ) 06/16/17: Resident #8, #9, #14, #17, #20, #24, #29, #35, #38, #40, #44, #45, 06/19/17: The assignment sheet did not reflect NA #22 had worked. The assignment list reflected NA #22 had worked on two (2) of two (2) hallways. During a follow-up interview with AA #2, at 1:45 p.m., she verbalized she had spoken with Administrator #1, and expressed she understood the facility failed to protect the residents by allowing NA #22 to continue working from 06/14/17 to 06/19/17. | 2020-09-01 |