cms_WV: 4797
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4797 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 224 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of accident/incident reports, facility policy and procedure review, and staff interview, the facility failed to implement its Abuse Prohibition written policies and procedures to ensure each resident had the right to be free from abuse. Resident #83 allegedly physically abused Residents #9 and #28. The facility had no evidence their abuse policies and procedures to investigate the abuse and to protect residents from abuse were implemented for either resident's alleged abuse. Resident identifiers: #9, #28, and #83. Facility census: 87. Findings include: a) Resident #9 On 11/04/15 at 8:40 a.m., a medical record review was conducted for Resident #9. This resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A continuing review of the medical record revealed this resident had capacity to make health care decisions. In addition, according to the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/15, Resident #9 had a score of 11 on the Brief Interview for Mental Status (BIMS), indicating the resident was only moderately cognitively impaired. A review of incident/accident reports, on 11/04/15 at 9:00 a.m., revealed on 07/18/15 at 4:40 p.m., Resident #9 was heard yelling while sitting in her wheelchair in the hallway. The report indicated Licensed Practical Nurse (LPN) #102 observed Resident #83 had his hands on the back of Resident #9's neck and was pushing her head forward. The incident/accident report event section indicated this was a resident-to-resident altercation with alleged abuse. The report noted the victim was Resident #9. The event section on Resident #83's incident report also indicated this was a resident-to-resident altercation, with alleged abuse. b) Resident #28 On 11/04/15 at 8:26 a.m., a medical record review was conducted for Resident #28. This resident was originally admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #28's score on the BIMS, on the annual MDS, with an ARD of 06/02/15, was 14, indicating cognition was intact. A review of incident/accident reports, on 11/04/15 at 9:12 a.m., revealed Resident #28 reported to nursing assistant (NA) #95 that she was in her wheelchair in the hallway when Resident #83 walked by and struck her in the right upper arm. A concurrent review of the accident/incident report for Resident #83 revealed the resident was ambulating on the Hilltop hallway and hit Resident #28 in the face. The incident/accident further stated, The next time she (Resident #28) stated that he (Resident #83) had hit her in the right arm. This resident could not give history of event. The event section of Resident #28's report indicated the incident was a resident-to-resident altercation with alleged abuse. The event section of Resident #83's report indicated the incident was a resident-to-resident altercation and Resident #83 was the alleged abuse/aggressor. c) On 11/04/15 at 9:15 a.m., the facility's policy and procedure titled Abuse Prohibition was reviewed. The Process section stated: 5. Staff will identify events --- such as suspicious bruising of patients, occurrences, patterns, and trends that constitute abuse --- and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.2 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. 5.2.3 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. There was no evidence the facility implemented its Abuse Prohibition policy and procedure regarding the allegations of abuse made by Residents #9 and #28. d) An interview was conducted with the Social Worker (SW) on 11/04/15 at 10:11 a.m When asked about the resident-to-resident altercations instigated by Resident #83 toward Residents #9 and #28, the SW stated because Residents #9 and #28 did not experience physical injury, nothing further was done related to the incidents. The SW stated This is how we look at them. When asked if the incidents constituted abuse, the SW did not reply to the question. The SW again stated, This is how we look at them. An additional question was asked regarding the fact the incident/accident reports indicated the incidents were each called resident-to-resident altercation with alleged abuse-victim, The SW stated this was probably assessed in error. The SW stated there was a drop down box for recording information, and the wrong information was indicated on each of the reports. | 2019-07-01 |