cms_WV: 2623
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2623 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 610 | D | 0 | 1 | F19R11 | Based on interview and record review, the facility failed to: a. Promptly initiate a thorough investigation of an allegation of abuse/neglect for one (Resident #59) of three sampled residents whose clinical records were reviewed for abuse/neglect. Resident #59 had informed a staff member of an allegation of neglect the morning of 11/29/18. No investigation was initiated until the afternoon of 12/03/18. b. Prevent potential further abuse/neglect by allowing the alleged perpetrator of abuse/neglect to provide care/services for residents for two 8-hour shifts following the facility's knowledge of an allegation of abuse/neglect. This affected one (Resident #59) of three sampled residents whose clinical records were reviewed for abuse/neglect. The facility census was 96. Findings include: On 12/03/18 at 10:56 AM, during an interview in Resident #59's room, Resident #59 stated on 11/29/18 she had used her call light at 2:00 AM and asked Certified Nurse Aide (CNA) #27 to be put on the bedpan. She stated she fell asleep and woke up at 4:00 AM and was still on the bedpan. She stated she used her call light but no one came. The resident stated she started crying and was hurting. Resident #59 stated she called the facility's phone number at 05:40 AM and Licensed Practical Nurse (LPN) #69 answered the phone. She stated LPN #69 was working on another floor and came down to her floor and told CNA #27 to get her off the bedpan. Resident #59 stated Assistant Director of Nursing (ADON) #110 talked to her later in the morning and stated ADON #110 would report the incident to the Director of Nursing (DON). The resident stated neither the Administrator or the DON had talked to her about the incident as of this interview date/time. On 12/03/18 at 2:11 PM, during an interview with the Administrator, the DON, Regional Director of Operations #1 and Regional Director of Operations #2, the Administrator was asked if she was aware of the above allegation of neglect involving Resident #59 and CNA #27. She stated she knew nothing of the incident. The Administrator stated it was the facility's policy that the Administrator be informed immediately of an allegation of abuse/neglect. The DON stated she had not heard of the incident nor had she seen any report of the incident. At 2:30 PM on 12/03/18, the Administrator provided statements from the ADON and CNA #27 which documented their version of the incident. The Administrator stated she had asked the ADON about the incident and she immediately gave her the statements. The Administrator stated the facility's abuse policy and procedure required notification to the state agency within 2 hours of an allegation of abuse/neglect. She stated, as of that time, the state agency had not been notified and no investigation had been conducted. She stated the ADON did not consider the incident neglect since the resident considered it an accident. The Administrator stated the ADON stated she was going to talk to the DON when she returned to the facility. The statement, taken by the ADON from the Resident #59 on 11/29/18, documented the resident told the ADON she was placed on the bedpan at 02:00 AM, fell asleep, woke up at 04:00 AM and turned her call bell on. The statement documented, No one came. Had to call facility . The statement documented the resident's roommate got out of bed to get help because I was in pain. This can't be happening there is no one to be found. How was she so busy she didn't remember I was on the damn bedpan . On 12/04/18 at 6:34 AM, ADON #110 was interviewed in the conference room. She stated she had been made aware of the incident the morning of 11/29/18. She stated the resident had approached her and she took the resident's statement about the incident. She stated she then went and informed the Nursing Staff Scheduler about the incident. The ADON stated she found out when CNA #27 worked again and asked the Nursing Staff Scheduler to obtain a statement from the CN[NAME] The ADON stated she received the statement from CNA #27 on 11/30/18 and planned to talk to the DON about the allegation on 12/03/18. The ADON stated she was mistaken in thinking the incident was an HR (human resources) situation or a teaching moment and did not consider neglect. The ADON stated the Administrator was present in the facility on 11/29/18 and 11/30/18 and she did not make the Administrator aware of the incident. The ADON stated, in hindsight, upon hearing about the allegation, she should have immediately notified the Administrator and the DON by phone. She stated she should also have notified the Human Resources Manager. She stated she should have reached out to CNA #27 herself and obtained a statement and, based on my responsibility of leadership, followed the next course of action. On 12/04/18 at 10:40 AM, the Nursing Staff Scheduler was interviewed in her office. She stated the ADON had informed her of the incident involving Resident #59 and CNA #27 the morning of 11/29/18. She stated she had not reported the incident to anyone on 11/29/18 but had gone to CNA #27 on 11/30/18 to get her statement. She stated she gave the CNA's statement to the ADON early morning on 11/30/18. She stated she had not reported the incident to anyone because, The ADON was handling it. She is my supervisor here. On 12/04/18 at 11:34 AM, the Administrator was interviewed in her office. She stated the allegation of neglect had not been recognized as such and had not been reported to the state agency. She stated the allegation had not been reported to the Administrator or a designee immediately. She stated a thorough investigation had not been completed as of this interview date/time. She stated residents had not been protected from the possibility of further neglect/abuse when the allegation was reported to the ADON by Resident #59. She stated she did not know how many shifts CNA #27 had worked since 11/29/18 and prior to her being suspended on 12/03/18. (The Administrator later reported CNA #27 had worked two shifts since the incident had occurred.) The Administrator was asked if the facility's abuse policy and procedure had been implemented to report, investigate and protect? She stated, No. The facility's Abuse & Neglect policy and procedure documented the following: Neglect: Neglect is the failure of the facility, its' employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (West Virginia) Code 9-6-1 defines neglect as the unreasonable failure by a caregiver to provide the care necessary to assure the physical safety or health of an incapacitated adult .The accurate and timely identification of any event which place our residents at risk is a primary concern of the facility .The following procedure will assist the staff in the identification of incidents and direct them to appropriate steps of intervention .Each .report of alleged abuse, neglect .will be identified and reported to the supervisor and investigated timely .The supervisor or designee will notify the Director of Nursing and Executive Director of the incident or allegation and no later than twenty four hours after being notified of incident or allegation and direct required notification of agencies, physician, family and resident representative .The Executive Director or designee will direct the investigation .The resident's condition will be stabilized by nursing, if appropriate .A physical examination will be performed by the Director of Nursing or nurse designee and documented in the clinical record .If the alleged perpetrator is a staff member that staff member will be removed from areas of resident living and interviewed by nurse of duty and asked to put their statement in writing, signed and dated .The staff member will be suspended .pending the outcome of the incident .The Executive Director / designee will report appropriate incidents to (state agencies), and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law .If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the self-report must be made immediately, but not later than 24 hours after the discovery . | 2020-09-01 |