cms_AK: 10
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-06-10 | 600 | D | 1 | 0 | TIZ611 | > Based on record review and interviews the facility failed to ensure 1 resident (#3) out of 4 sampled residents was protected from verbally and physically assaultive behavior by staff. This failed practice placed the resident at risk for psychosocial and physical harm from abusive staff behaviors. The facility had implemented corrections prior to the investigation. Findings: Record review on 6/7/19 revealed Resident #3 had a disorder that resulted in dementia, mood disorders, and uncoordinated muscle movements. The Resident was one of several residents on the unit on enhanced observation (individual staff that monitored the resident one to one, due to a high fall risk). Review of the report provided to the State Agency on 6/3/19 revealed on 5/30/19 at approximately 7:30 pm, Licensed Practical Nurse (LPN) #1, who had been assigned to provide enhanced observation of the Resident, was to be heard 'screaming' at the Resident and telling (him/her) couldn't come out of (his/her) room. (LPN #1) was further noted to be yanking at the Resident's shirt attempting to pull (him/her) back in the bed, by force. Further review revealed Certified Nursing Assistant (CNA) #s 1 and 2 interceded, redirected the Resident, and reported the event to the Registered Nurse (RN) that was in charge on 5/30/19. The RN assessed the Resident, administered his/her evening medications and assisted the Resident back to (his/her) room. The Resident did choose to have (LPN #1) remain sitting with (him/her) rather than a new and unknown CNA floated from outside the unit. LPN #1 continued to provide enhanced observation of the Resident the remainder of the night. During an interview on 6/6/19 at 8:30 pm, LPN #2 stated he/she had been left out of the loop. The LPN stated the evening of 5/30/19, the CNAs had mentioned there had been a confrontation, as Resident #3 is normally very vocal, LPN #2 stated he/she planned to address it when after he/she finished passing medications. The LPN stated when he/she checked the Resident was sleeping and LPN #1 was seated at the Resident's bedside. During the interview, when asked if there had been earlier indicators of abuse by LPN #1, LPN #2 stated LPN #1 would make statements such as Resident #3 can't always get (his/her) own way. During an interview on 6/7/19 at 4:00 pm, Registered Nurse (RN) #1 stated he/she was the charge nurse that night. When asked about the event that had transpired between Resident #3 and LPN #1 the RN stated he/she did not hear the confrontation. After the CNAs notified him/her, the RN examined the Resident and observed pink marks around his/her neck. When she/he asked about the incident, Resident #3 stated, I don't like (LPN #1) and was tearful, but not hysterical. The RN stated because a change in staffing or scheduling could easily upset the Resident, he/she asked Resident #3 if he/she wanted LPN #1 to remain in the room or provide different staff from the hospital. The Resident chose to have LPN #1 remain the rest of the night. The RN stated it was quiet the remainder of the night. The RN stated he/she was unaware there was a specific protocol for protecting the residents that needed to be followed. During an interview on 6/7/19 at 4:15 pm, CNA #1 stated he/she and CNA #2 were working the evening of 5/30/19 and had witnessed the incident. CNA #1 stated LPN #1 had ahold of the Resident by the collar of the shirt and had yanked the shirt so hard it caused red marks around the Resident's neck. The CNA stated LPN #1 was verbally arguing with the Resident and made the statement Resident #3 cannot always get (his/her) own way. CNA #2 interceded and redirected the Resident, who was agreeable with putting on slippers and a gait belt for his/her evening walk to the nurses' desk for his/her medication. CNA #1 stated he/she immediately notified the charge nurse of the event and reported it to the Director of Nursing (DON) the next morning. In addition, the CNA stated he/she was surprised the red marks on the Resident's neck had faded by the morning. Corrections: During an interview with the DON on 6/7/19 at 4:30 pm stated he/she had learned of the altercation between Resident #3 and LPN #1 the next morning. The DON stated the LPN #1 was from a travel agency and they ended the nurse's contract early, the facility also reported the abusive behavior to the State Agency and the contracting travel agency. The DON stated he/she had notified the Resident's spouse, who had not been aware of the event. In addition, the DON stated he/she had conducted education for all staff on 6/5/19 regarding the reporting, investigation, and protection requirements. Several staff were interviewed regarding the training and confirmed they had attended. The content of the in-service titled State Reporting and Investigation of Suspected Abuse/Neglect of Resident and the Federal Elder Justice Act and the sign in sheet was reviewed. The Surveyor confirmed LPN #1 was no longer employed at the facility. | 2020-09-01 |