cms_WV: 4787
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4787 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 225 | F | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, medical record review, policy review, reive of personnel records, and the Affordable Care Act, the facility failed to ensuer they screened one (1) of ten (10) employees by not ensuring they completed crominal background checks. Additionally, they failed to throughly investigate and report allegations of abuse/neglect for three 93) of nine (9) residents reviewed for abuse and neglect. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related that he felt like staff did not want to come to his room at times. He related he believed he had been vervbally abused. The resident related the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionall, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practice nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty 930) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW #76). The minimum datea set (MDS) with an assessment reference date (ARD) of 10/20/15, reviewed on 01/14/5 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facaility had filed/reported an allegation of neglect on Resident #48's behalf. During an inteview with SW #76 on 01/19/16 at 11:53 a.m., she related Resident #48 often called her into his room as she was walking down the hall. The SW said, the resident complained that his alarm would go off and he said he waited for someone to answer the alarm. She related resident told her he felt like staff did not want to come in there at times. SW #76 related the resident dold her he had been left in urine and feces, but denied neglect, and did not want it reported. She related, I told him, now you know I hace to report this, are you sure? The social worker related she would review tapes and interview staff. On 01/19/16 at 2:45 p.m., another interview with SW #76 revealed she tried to determine what actually happened prior to reporting incidents. The social worker related if a concern/complaint/allegation was made, she would say to the staff, This is what I was told and try to determine what actually occurred, and if deemed reportable, would report it. During an interview with Resident #48, on 01/20/16 at 8:35 a.m., the resident related the social worker had not visited him this week (Monday, Tuesday or Wednesday). He related he was not notified of the outcome of the concerns/allegations he had reported. Additionally, the resident related he did not know how to report to the appropriate state agencies, only the facility staff. A follow-up inteview with SW #76 on 01/20/16 at 3:30 p.m., confirmed no reports had been filed related to Resident #48's allegations, and the SW was unable to provide evidence the allegations were investigated. b) Residen #77 A review of reportable allegations, on 01/13/16 at 3:30 p.m., revealed a noted dated 11/21/15 at 7:14 p.m., and signed by the Licensed Practical Nurse (LPN) #93. The report indicated a family member had reported to LPN #101 that Resident #77 was out of the facility. Staff immediately contacted (local) Police Department and began searching in and out of the facility. LPN #95 and minimum data set (MDS) Nurse #78 reviewed the cameras, which indicated the resident was last seen walking toward the water tower and up the hill behind the facility at 11:24 a.m. Inspection of the courtyard revealed knee prints, and wires that were holding the fencing to the pole together were untwisted. The physical area was fixed to prevent further elopement. The report did not indicate what time the resident was reported as missing, nor did it provide any inforamtion regarding staffs lack of awareness that the resident was missing. The Immediate Fax reporting of allegation form indicated the time of the incident as 11:24 a.m. on the 440-hall west side courtyard. The reports indicated a search was inside and outside of the facility, and was found about one (1) mile away, heading back towards the facility. The form did not indicate the time the search was initiated, nor the time the resident was found. An interview with Licensed Practical Nurse #93 (LPN), on 01/13/16 at 3:59 p.m., revealed Resident #77 had eloped under the fence in the courtyard near the administrator's office. The LPN related another nurse had called and related someone had seen the resident and the facility transported him back. When asked how the facility identified how the resident eloped, the LPN related staff had watched the cameras. LPN #77 related she could not remember whether staff completed witness statements related to the event. LPN #93 related the 911 emergency lines, and the police were called to make sure the resident was safely found. LPN #93 reviewed the medical record and confirmed the record did not indicate at what time the resident was reported missing. nor the time of his return. She related she could not remember. Further inquiry, revealed she was the unit charge nurse at the time of the incident. The LPN related staff had not reported an inability to locate the resident prior to the family notifiying the facility. LPN #93 related she was unaware of any follow-up intervention related to staff oversight of residents. The nurse indicated staff had not reported the resident as unavailable during smoke breaks or for lunch. An interview with the 911 center, on 01/19/16 at 1:29 p.m., revealed the facility called in the elopement at 15:06 (3:06) p.m. on 11/21/15. Upon inquiry as to who completed the investigation, LPN #93 related she believed the social worker was responsible. Additionally, interviews, with the Activity Director (AD) on 01/12/16 at 2:42 p.m. and Registered nurse #18 (RN), on 01/13/16 at 9:50 a.m., also related the social worker completed investigation of abuse and neglect when she returned to work. On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy. located in a binder at the nurses' station, revealed the chain of command reported to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. An interview with Social Worker #76 (SW), indicated the incident occurred on a weekend. She relaled the director of nursing would have been notified first, and a registered nurse supervisor (RN #18) was present and informed her. She further related the facility fixed the areas right then and there. The SW related the fence was relatively new and had been built as a non-smoking area. During another interview with SW #76, on 01/14/16 at 9:29 a.m., the SW related the facility was not aware Resident #77 had been a flight risk. She did relate, however, the resident had blamed her and said she was keeping him hostage at the facility. SW#76 reviewed the reportable allegation and related she believed the resident returned to the facility earlier than the note, which was dated and times as 11/21/15 at 7:14 p.m. When asked how long the resident had been missing prior to staff's awareness. the social worker related she did not know. Further review of the medical record, on 01/14/16 at 9:51 a.m., revealed [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (dizziness), diabetes mellitus, hypertension, and [MEDICAL CONDITION]. The brief interview for mental status (SIMS) score was eleven (11) which indicated cognitive impairment. The immediate five (5) day follow-up completed by SW #76 noted, Resident was/did elope from facility while staff not watching. Resident was found by staff and brought back to the facility safe with only minor redness and scrapes . The social worker confirmed no evidence was present to indicate staff had been interviewed, or the incident had been thoroughly investigated to ensure the resident had been adequately supervised at the time of the elopement. c) Resident #106 Review of concerns and grievances, on 01/18/15 revealed an allegation dated 11 123f15 by Licensed Practical Nurse #107 (LPN) which indicated a responsible party had called the facility on 11/22/15 alleging abuse of Resident #106. The allegation indicated Resident #106 had not received her medication ([MEDICATION NAME]) and was treated for [REDACTED]. The hospital told me she was overdosed, and you shouldn't (should not) be asking me if she's (she is) confused you should do your job and read through her chart A note. dated 11/23/15 indicated Assistant Director of Nursing #34 (ADON) had called the daughter to request a meeting. No evidence was present to indicate the allegation of abuse had been reported to the approoriate state agencies. An interview, with Social Worker #76 (SW) confirmed the event had not been reported to state agencies. She related the director of nursing (DON) had handled it, and that she had not reviewed it. d) Criminal background checks The Affordable Care Act and West Virginia Code Chapter 16, Article 49 required direct access employees of nursing facilities, at a minimum, to complete a State and Federal fingerprint-based criminal investigation background checks prior to hire. Personnel records. reviewed on 01/13/16 at 1:52 p.m. with Medical Records #70 (MR) revealed no evidence the facility completed a State and Federal criminal background check for Physical Therapist #108 (PT), prior to hire on 10/15/15. On 01/13/16 at 2:55 p.m., a review of the time sheet, on 3116 at 2:55 p.m., confirmed PT #108 had worked on 11/27/15, 12/19/15, 12/24/15, and 01/01/16. An interview with the administrator on 01/ at 3:20 p.m. revealed the contracted company was responsible for completing criminal background checks, and confirmed a fingerprint background check had not been completed. A review of the facility policy revealed the following in regards to screening employees: In order to protect all residents. during the hiring process a newly hired employee will be screened. This will be accomplished through the local law enforcement, state police and other agencies. Once the checks have been completed and show no evidence of abuse or neglect the emr:loyee will then be fingerprinted and a background check is then initiated. The employee will be allowed to work until the background check comes back to facility. If the report is unfavorable, the individual will be terminated immediately. | 2019-07-01 |