cms_WV: 5948
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5948 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 490 | E | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident council meeting minutes, policy review, resident interview, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility had no system in place which ensured all allegations involving mistreatment, neglect, abuse, and misappropriation of resident property were reported to the proper State authorities in accordance with State law and were thoroughly investigated by facility staff. In addition, the facility failed to act upon and/or communicate decisions made about the issues identified in resident council meetings. Affected residents included Residents #21 and #37; however, these systemic problems had the potential to affect more than a limited number of residents. Facility census: 104. Findings include: a) Allegations of Verbal Abuse 1. Resident #21 On 12/30/14 at 3:40 p.m., a review of resident council minutes, dated 10/20/14, revealed Resident #21 was one (1) of two (2) residents who alleged some of the night shift nurses were very rude and sassy with the residents. A departmental response form from the nursing department, dated 11/17/14 and stamped second notice given 11/10/14, indicated two (2) residents stated the night nurses were very rude and sassy with us. No specific names were given at the meeting. The response actions taken to resolve the issue identified was, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. There was no indication this allegation of abuse was reported or investigated. A review of the reportable abuse/neglect records, on 12/31/14 at 8:40 a.m., revealed no evidence that allegations of nursing staff verbally abusing Resident #21 were reported or investigated. On 12/31/14 at 11:43 a.m., review of Resident #21's minimum data set (MDS) with the assessment reference date (ARD) of 10/29/14, revealed the resident scored 14 on the brief interview for mental status (BIMS). A score from 13 -15 on the BIMS indicated a person was cognitively intact. An interview with Resident #21, on 12/31/14 at 11:55 a.m., revealed .some of the night nurses can be a little rough speaking and rude .I am not sure of their names. I try not to deal with them when I can. It's not as bad now as it was since someone talked to them. Resident #21 requested to end the interview due to not feeling well. On 12/31/14 at 10:12 a.m., an interview was conducted with Employee #124 (resident council liaison) concerning the issue of resident council members stating some of the night nurses were 'very rude and sassy.' Employee #124 was asked, What did you do with that information? The response from Employee #124 was, I knew it was a nursing issue, so I took it to the director of nursing. I did not think of it as verbal abuse at that time or I would have also taken it to the social worker and filled out the paperwork . Now that I think about it, it may be considered verbal abuse. Employee #124 agreed if it had been investigated, it might have been discovered who the staff were that were involved in the allegation, or what occurred. An interview with the director of nursing (DON), on 12/30/14 at 5:15 p.m., revealed nursing had monthly meetings with agendas and sign-in sheets for the nurses and aides. The DON provided the agenda and sign-in sheets for the December monthly nursing meeting. It had an agenda item which stated, Reports from residents r/t (related to) rudeness/sassiness by staff to them -UNACCEPTABLE. During an interview with the DON, on 12/31/14 at 10:35 a.m., the nursing departmental response form dated 11/17/14 was reviewed. Under the section titled response/actions taken by department in reference to rudeness/sassiness by nursing staff, the DON had written in the response section, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. When asked if the complaint had been investigated, the DON replied, No. I did not think of it as a complaint. It was pointed out that she had used the word complaint in her departmental response. The DON agreed it should have been investigated. 2. Resident #37 On 12/30/14 at 3:40 p.m., review of resident council minutes, dated 10/20/14, revealed Resident #37 was the other of the two (2) residents that alleged Some of the night shift nurses are very rude and sassy with us. During an interview with Resident #37, on 12/30/14 at 4:37 p.m., when asked if nurses were ever rude to her, she stated, .some of them at night can be rude and grouchy, not all of them, some treat you real good. She said other council members also agreed the night nurses were rude. A review of reportable records containing allegations of abuse/neglect, on 12/31/14 at 8:40 a.m., revealed no evidence the allegation of nursing staff verbally abusing Resident #37 was reported or investigated On 12/31/14 at 11:43 a.m.,review of Resident #37's minimum data set (MDS), with the assessment reference date (ARD) 10/21/14, revealed the resident scored 15 on their brief interview for mental status (BIMS). A score from 13 -15 on the BIMS indicated a person was cognitively intact. 3. Review of the facility's abuse policy, on 12/31/14 at 12:15 p.m., revealed Any staff member witnessing, receives a complaint of, or suspects mistreatment, neglect and/or abuse is to immediately report it to their immediate supervisor. All state specific requirements for reporting any allegation of abuse or neglect shall be followed. The allegation will be reported to the Administrator, DON, or designee and all other agencies as required by state law within twenty four (24) hours of the occurrence. An assistant administrator or social worker will complete the investigation and notify the required agencies in five (5) days of the allegation. The policy also directed staff to notify the executive director or social services supervisor. The allegations of abuse made by Residents #21 and #37 were not reported or investigated. The resident council liaison and the DON failed to identify that Some of the night shift nurses are very rude and sassy with us, as expressed at the resident council meeting, was an allegation of abuse which required reporting and an investigation. b) Resident council concerns and grievances 1) On 12/30/2014 at 3:40 p.m., the resident council minutes were reviewed. The review revealed the following: 1. The meeting minutes from 08/18/14 revealed the residents wanted buckwheat cakes on some mornings. They also said they would like to have a swing and a few lawn chairs for the courtyard. The activity director was interviewed on 12/30/14 at 3:40 p.m. She indicated she did not know if the residents had received the buckwheat cakes. The facility had no evidence to show they had communicated this request to the dietary department. They also had no evidence they had communicated back to the council members about their request for buckwheat cakes. On 12/30/14 at 4:25 p.m., during an interview with the certified activity director (Employee #124), she said the facility had decided, due to the construction that was going on in the courtyard area, the facility had decided to wait until spring to purchase the lawn chairs and swing. She was asked if the resident council members had been informed of the facility's decision to wait until spring to make the purchases. She said, No, as far as I know they have not. 2. On 09/15/14, the council met. The residents complained their vegetables were cooked to death. The response/actions on the attached dietary departmental response form showed that some residents liked their vegetables cooked soft so they can chew them, and other residents liked them crisp. The dietary department indicated they would begin batch cooking and were trying to give residents their preferences. There was no evidence this information was relayed to the council members. 3. The other issue mentioned in September was the time of evening medications. Residents complained nursing staff were waking them up to give their evening medications. The preference from the residents was for medications to be given before 9:00 p.m. The attached departmental response from the facility indicated one (1) resident from the meeting already had their last medication of the day at 5:30 p.m. The response also indicated one (1) of the residents had a physician's orders [REDACTED]. The facility sent a message to all nurses related to timely medication administration. During an interview with the director of nursing (DON), on 12/30/14 at 5:15 p.m., she said she had taken steps to resolve the issue of residents not getting evening medications timely, and not being awakened to receive medication at night. She said the nurses were re-educated in October 2014. She provided sign-in sheets for the October 2014 meeting. There was no evidence these actions were communicated to the residents in resident council and/or that the residents were satisfied with the facility's resolution. 4. Meeting minutes from the 10/20/14 meeting revealed two (2) residents said some of the night shift nurses were very rude and sassy with them. Attached to the meeting minutes was a departmental response form from the nursing department. It was dated 11/17/14 and stamped 2nd Notice given 11/10/14. The response form indicated two (2) residents had said the night shift nurses were rude and sassy with them. The form said no specific names were given in the council meeting. The facility documented the response action to resolve the issue was to have a meeting with all nursing staff on 12/02/14. The form did not indicate this issue was reported as an allegation of abuse or investigated as an allegation of abuse. On 12/31/14 at 10:12 a.m., Employee #124 was interviewed concerning the issue of resident council members stating some of the night nurses were very rude and sassy. Employee #124 said she knew this was a nursing issue, so she reported it to the director of nursing. She said she did not think it was abuse or she would have informed the social worker. During the discussion, she agreed the issue was an allegation of abuse and agreed if it had been investigated then the facility may have determined who was involved in the allegation and what actually occurred. During an interview with the director of nursing (DON), on 12/31/14 at 10:35 a.m., she said the facility had discussed this issue with nursing staff on 12/02/14. There was no evidence the residents were made aware this issue was discussed with nursing staff. There was also no evidence the facility followed up with the residents to ensure they no longer had concerns with the way they were treated during the night shift by nursing staff. The DON said the facility had not reported or investigated this as an allegation of abuse. She agreed it should have been reported and investigated. 5. On 12/30/14 at 5:45 p.m., during an interview with the administrator, she stated the forms for resident council meetings, and departmental response forms were developed because the facility had a deficient practice in the past concerning resident council. She thought these forms had resolved the issues and she did not know there was a problem. The administrator agreed if the forms were used, and sections completed in their entirety with pertinent information, they would be a useful way to demonstrate the facility's coordination and communication with the resident council. | 2018-05-01 |