| 58 |
WRANGELL MEDICAL CENTER LTC |
25015 |
P.O. BOX 1081 |
WRANGELL |
AK |
99929 |
2018-04-30 |
600 |
D |
0 |
1 |
O8F911 |
Based on record review and interviews the facility failed to ensure 1 resident (#10), out of 8 sampled residents, was free from verbal abuse during cares. This failed practice placed the resident at risk for further mistreatment, undo stress/suffering and a less than optimal psychosocial environment. Findings: Record review on 4/23-27/18, of Resident #10's care plan, dated 2/12/18, revealed he/she was wheelchair bound and requires mechanical lift (machine used to move a resident), using 2 staff members for transfers. During an interview on 4/25/18 at 1:28 pm, Resident #10 stated that approximately a week ago CNA #3 was helping him/her, slipped, and caused the bar of the mechanical lift to hit the area above the Resident's right eye. The Resident had requested CNA #4 to help him/her instead. The Resident further stated that CNA #3 got frustrated, took off his/her gloves, threw them in the trash can and in a raised voice said, I am never going to help you again. The Resident further stated soon after this, a LN (licensed nurse) asked CNA #3 to help get Resident #10 into bed. Resident #10 stated he/she saw CNA #3 whisper in the LN's ear and left the area. After this, the LN obtained another CNA to help the Resident that day. Resident #10 stated this event made him/her feel like CNA #3 did not want to work with him/her. During an interview on 4/27/18 10:30 am, the Chief Nursing Officer (CNO) stated she was informed that Resident #10's head was bumped by the mechanical lift and the Resident requested a different CN[NAME] She further stated it was her understanding that CNA #3 removed his/her gloves and stated he/she wasn't going to help anymore. When asked about the manner in which CNA #3 spoke to the Resident, the CNO stated she was unaware that CNA #3 spoke to Resident #10 in a raised voice. When the Surveyor asked if the CNO felt the incident of how the staff spoke the Resident was a reportable incident, CNO replied, I understand it's reportable if there was a bump or bruise. After surveyor showed the CNO the mandatory reporting criteria of any allegation, perception, suspicion, or observation of any type of abuse from the Wrangell Medical Center Event Mandatory Reporting Form, dated 5/2/16, the CNO stated, Yes, it needs to be reported. CNO concluded by stating the facility had not filed a report with the State Survey Agency concerning this incident. During an interview on 4/27/18 at 1:15 pm, CNA #3 stated he/she was assisting Resident #10 in a transfer when a his/her scrub pocket got caught on a piece of the mechanical lift. As a result, this caused the arm of the lift to swing and make contact with the right side of the Resident's face. The CNA further stated the Resident wanted a different CNA to assist. In response, CNA #3 stated he/she removed gloves and left the room. CNA #3 denied saying anything to Resident. During an interview on 4/27/18 at 2:00 pm, CNA #4 stated he/she was going to take over assisting Resident #10 with transfer when he/she approached the door and noted that CNA #3 had accidently bumped the Resident's forehead with the mechanical lift. CNA #4 stated the Resident requested that he/she should assist instead of CNA #3. CNA #4 further stated that CNA #3 became angry and threw his/her gloves into the trash and stated to the Resident I won't help you again. CNA #4 stated he/she filled out a Stop and Watch form (document filled out when any identified changes occur) and immediately reported the incident to the CNO and while handing in the Stop and Watch form. During an interview on 4/26/18 at 3:10 pm, the CNO confirmed when a Stop and Watch form is completed it does go to her for review. When surveyor asked to see past Stop and Watch forms, the CNO stated, no one knows where the past forms are and did not produce past forms. Review of Wrangell Medical Center's Policy and Procedure of Abuse Prevention and Protection from Abuse and Neglect in the Vulnerable Adult, dated 3/2017, stated under Prevention: Management and staff will remain alert for signs of stress, fatigue, or inappropriate behavior among their peers. Inappropriate language, rough handling, or failure to attend to a resident's care needs will not be tolerated. Review of Wrangell Medical Center's Policy and Procedure of Incident/Adverse Reporting Policy, dated 4/2017, revealed Any incident involving a patient/resident that involves alleged mistreatment, abuse, or neglect, misappropriation of property, injury of unknown origin or unwitnessed falls will be reported within 24 hours to the State of Alaska Department of Health and Social Services, Certification & Licensing. |
2020-09-01 |