| 59 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2019-03-02 |
600 |
J |
1 |
0 |
KDKT11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of Resident Identifier (RI) #1, RI #2's medical record, RI #3's medical record, the facility's policy titled OPS300 Abuse Prohibition and the facility's investigative file, the facility failed to ensure RI #2 and RI #3 were free from abuse perpetrated by RI #1, a resident who resides on the Homestead Memory Care (Dementia) Unit. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1, a resident identified as being physically aggressive toward others, struck RI #2 with no warning or provocation and physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the evening shift on 2/20/2019, around supper time, the intervention of 1:1 supervision/oversight was not implemented and RI #1 was found by staff standing over RI #2, punching RI #2 in the head. This deficient practice affected RI #2 and RI #3, two of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's policy titled, OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY Genesis HealthCare Centers will prohibit abuse . for all residents . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting, slapping, pinching, kicking, etc., . 1) RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/23/2018, indicated RI #1 was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 2. For one to three days during this assessment period, RI #1 displayed physical and verbal behavior symptoms directed toward others. RI #2 was admitted to the facility on [DATE]. RI #2 has a medical history to include [DIAGNOSES REDACTED]. RI #2's Quarterly MDS with an assessment reference date of 11/28/2018, indicated RI #2 was severely impaired in cognitive skills for daily decision making, with a BIMS score of 4. For one to three days during this assessment period, RI #2 displayed verbal behavior symptoms directed toward others. On 2/15/2019, the facility reported an allegation of physical abuse to the Alabama State Survey Agency. According to the report, . (RI #1) and (RI #2) were ambulating in hallway toward one another. (RI #1) struck (RI #2) with (his/her) R (right) fist on (RI #2's) chin . Action(s) taken by the facility in response to the incident: . (RI #1) placed on 1:1 observation until referral to geri-psychiatric services . The facility's investigative summary dated 2/22/2019, documented . On (MONTH) 15, 2019, at approximately 7:45 PM, LPN (Licensed Practical Nurse) (EI (Employee Identifier) #4) was exiting Resident room [ROOM NUMBER] when she observed (RI #1) and (RI #2) walking towards one another. (EI #4) observed (RI #1) say something towards (RI #2), and then strike (RI #2) on (his/her) chin with a closed fist. The Nurse intervened to prevent further contact . Center Conclusions. RI #1 struck RI #2 with no warning or provocation . physical abuse did occur. From (MONTH) 15, 2019 until (MONTH) 21, 2019, RI #1 was provided 1:1 oversight during (his/her) waking hours. On (MONTH) 21, 2019, (he/she) was transferred to the acute geri-psychiatric setting . On 2/22/2019, anonymous callers reported to the Alabama State Survey Agency that RI #1 had repeatedly physically abused other residents on the Dementia Unit. According to the callers, earlier in the week during the second shift, RI #1 punched RI #2 in the chin. Then during the second shift on 2/20/2019, RI #1 was seen punching RI #2 in the face. The callers stated it was impossible for someone to watch RI #1 1:1 during the second shift because they were understaffed. During a telephone interview on 2/27/2019 at 9:31 AM, EI #5, a Certified Nursing Assistant (CNA) acknowledged she witnessed RI #1 hit RI #2 on 2/20/2019. When asked what she did observe, EI #5 stated as she was walking down hall she looked over in RI #2's room and saw RI #1 punching RI #2 in the head. When asked where RI #2 was, EI #5 said RI #2 was sitting on the bed and RI #1 was standing over RI #2 hitting him/her. According to EI #5, another CNA (EI #6) came over and asked what was going on. Also, EI #7, a CNA and EI #4, the LPN responded when EI #4 called for help. EI #5 stated she removed RI #1 from the room and asked the resident what was wrong. EI #5 replied, RI #1 told her that's ok I have taken care of the problem it has been going on 14 days. EI #5 was asked if she observed any injuries to either resident. EI #5 replied, she didn't see any injuries to RI #2 but RI #1's knuckles were red. EI #5 stated the nurse, EI #4, was made aware of what occurred. When asked if RI #1 was ever on 1:1, EI #5 stated before RI #1 hit RI #2 the second time (2/20/2019), RI #1 was on 1:1 for about a day. EI #5 stated she didn't know RI #1 was 1:1 when the second incident (2/20/2019) happened. During a telephone interview on 2/27/2019 at 10:36 AM, EI #7, a CNA acknowledged that she worked in the facility's locked (Dementia) unit during the second shift on 2/20/2019. When asked if she was familiar with RI #1, EI #7 said yes. EI #7 described RI #1 as being alert but very confused. EI #7 was asked, who was assigned to care for RI #1 during the second shift on 2/20/2019. EI #7 replied, EI #6 was. When asked if she witnessed RI #1 hitting RI #2 on 2/20/2019, EI #7 replied no. EI #7 was asked when she became aware of the altercation. EI #7 explained that the nurse, EI #4, had asked her to take a resident to the bathroom, when she heard EI #7 holler help or something to that nature. EI #7 stated she stopped what she was doing and went to RI #2's room; however, EI #6 was already there. According to EI #7, EI #5 said she went into the room and noticed RI #1 on top of RI #2 beating RI #2 with his/her fist. When asked if the nurse, EI #4, was notified of the altercation, EI #7 said yes. EI #7 stated the nurse told her that she had contacted the Director of Nursing Service (DNS), who stated to not do anything that she (DNS) would take care of it in the morning. EI #7 was asked if RI #1 was supposed to be on 1:1 on 2/20/2019. EI #7 replied, she wasn't sure. When asked if RI #1 had been on 1:1, EI #7 said yes she had heard that RI #1 was on 1:1 before, but EI #7 said she didn't think RI #1 was on 1:1 when she worked in the facility. EI #7 was asked how the CNAs would know if a resident was placed on 1:1 and she replied, I guess the nurse or supervisor would tell us. In an interview on 2/27/2019 at 3:45 PM, EI #6 acknowledged that she was assigned to care for RI #1 during the 2:00 PM to 10:00 PM shift on 2/20/2019. When asked if RI #1 was on 1:1 during her shift on 2/20/2019, EI #6 said no, the staff had been told that RI #1 was taken off 1:1. EI #6 explained that if RI #1 was 1:1, there would have been a paper with names on it to let the staff know what time they were assigned to watch RI #1, but when she came in there was no sheet to let the staff know the resident was on 1:1. When asked when RI #1's 1:1 was discontinued, EI #6 said she didn't know. EI #6 was asked if there was altercation between RI #1 and RI #2 on 2/20/2019. EI #6 answered, yes. When asked what happened, EI #6 said it was during supper time and she was in the middle of feeding another resident when EI #5 observed RI #2 sitting on the bed and RI #1 punching RI #2 in the face. EI #6 stated when she entered RI #2's room she could tell that RI #1 had hit RI #2 because RI #1's knuckles on both of his/her hands were red and RI #1 was sweating. Also, EI #6 stated the left side of RI #2's face looked bruised. According to EI #6, the nurse, EI #4, notified the DNS, who told her not to call RI #2's family, that the staff was going to be written up because they were not watching RI #1 and that she (DNS) would take care of things the next day. On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) LPN assigned to work on the Homestead (Dementia) Unit. When asked if she was familiar with RI #1, EI #4 said yes. EI #4 stated RI #1 was a nice resident most of the time. According to EI #4, RI #1 did have a problem where he/she hit two residents. EI #4 explained on 12/16/2018, RI #1 knocked RI #3's tooth out. Then on 2/15/2019, EI #4 explained that she was coming out of room [ROOM NUMBER] and saw RI #1 hit RI #2 under the chin. EI #4 stated she yelled and got in between both residents. Afterwards, EI #4 stated she notified the Director of Nursing Service (DNS). When asked if she had been told to place RI #1 on 1:1, EI #4 said yes. When asked what 1:1 meant, EI #4 said that someone is with the resident at all times. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later, EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS asked her what happened to the 1:1. EI #4 stated this was the first time she knew that 1:1 should have continued. EI #4 explained she didn't know the resident was still to be on 1:1. When asked if she documented the 2/20/2019 altercation, EI #4 said she did not. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. RI #1's Merry [NAME] Lodge Progress Notes written by EI #4, a LPN and dated 2/15/2019 at 9:48 PM, documented the following: . Note: A change in condition has been noted. The symptoms include: Other change in condition Hit another resident 02/15/2019 in the afternoon . A review of RI #1's medical record revealed no documentation regarding the 2/20/2019 incident in which RI #1 was observed punching another resident, RI #2, in the head. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, she was asked if she was familiar with RI #1. EI #2 said yes. When asked if RI #1 had behaviors, EI #2 said yes, the resident would become aggressive with staff during care and there were resident-to-resident altercations, where RI #1 would strike other residents. EI #2 was asked if resident-to-resident altercations were reportable to the State Survey Agency and she said yes. When asked what happened during the resident-to-resident altercation that occurred on 2/15/2019, EI #2 said the altercation involved RI #1 and RI #2. The nurse said both residents were ambulating in the hallway and RI #1 mumbled something and then hit RI #2 under the chin without provocation. When asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1 and there were no new interventions for RI #2 after the resident was assessed for injury. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignments sheets and put them on the unit. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 stated there was a certain amount of trust she had with the Charge Nurses that they would do their job. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked should the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegation within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred, and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied, I don't know. I would never do that. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged that RI #1 was placed on 1:1 after the resident had been observed by staff to strike RI #2 under the chin on 2/15/2019 until other placement could be achieved; RI #1 was discharged from the facility on 2/21/2019. When asked should 1:1 have continued until RI #1 was discharged , EI #1 stated I thought it did but I now know that on 2/20/19, (RI #1) was observed in (RI #2's) room and was hitting (RI #2) in the face. According to EI #1, he was not made aware of this incident until 2/27/2019. 2) RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/23/2018, indicated RI #1 was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status (BIMS) score of 2. For one to three days during this assessment period, RI #1 displayed physical and verbal behavior symptoms directed toward others. RI #3 was admitted to the facility on [DATE]. RI #3 has a medical history to include [DIAGNOSES REDACTED]. RI #3's Quarterly MDS with an assessment reference date of 11/30/2018 indicated RI #3 was severely impaired in cognitive skills for daily decision making with a BIMS of 2. During this assessment period, RI #3 was not identified as displaying any behaviors. According to the facility's investigative file, on 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. RI #1 denied any physical altercation. RI #3, who has a [DIAGNOSES REDACTED]. Law enforcement and the residents' families were notified. Both residents were sent to the local hospital for evaluation. RI #1 returned to the facility later that evening and RI #3 was admitted . On 1/28/2019, RI #1 was transferred to Geri-Psych at a local hospital. There were no witnesses to the incident. Both residents reside on the Memory Care Unit of the facility and they were roommates. The facility concluded that physical abuse occurred; however, they were unable to identify the aggressor or instigator. As the result of the incident, RI #3 was moved to another room when he/she returned to the facility. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if RI #1 and RI #3 still shared a room when the 1/25/2019 incident occurred, EI #2 said yes because the facility could not determine whether a resident-to-resident altercation occurred on 12/26/2018 because there was no witnesses and the residents were unable to tell what happened. EI #2 explained that after the 1/25/2019, the same general interventions of close monitoring was in place since the facility treated this incident as a fall. According to EI #2, while there were no witnesses, one could tell something had occurred because RI #1 had blood on his/her knuckles and the trail of blood on the floor led to RI #3, who was found, in the shared room of both residents (RI #1 and RI #3), bleeding from the mouth. EI #2 stated after this incident RI #1 was placed on 1:1 until send out to a Geri-Psych setting. Then on 2/1/2019. the physician came in to assess RI #1 and determined that 1:1 was no longer needed. When asked how the facility monitored RI #1's aggressive behaviors after the 1/25/2019 incident, EI #2 said the same general interventions of monitoring. In an interview with RI #3 on 2/26/2019 at 11:03 AM, the resident was asked if he/she had ever been in a fight or had someone hit him/her while in the facility. RI #3 replied, We both hit each other. When asked why each resident hit each other, RI #3 stated the other resident had hit him/her. When asked who hit first, RI #3 replied the other resident hit him/her first. RI #3 was asked where was he/she hit and the resident replied, on my head. When RI #3 was asked if he/she was hurt, the resident stated no we just hit each other. ************************* On 03/02/19 at 7:15 p.m., the facility submitted an Allegation of Credible Compliance for F 600, which documented: F-600J-Freedom from Abuse and Neglect * Licensed Nurse discharged RI #1 to (local geri-psychiatric facility) on (MONTH) 21, 2019. * As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. * Interdisciplinary Team interviewed 7 of 7 residents deemed as interviewable on Homestead and/or with BIMs score ranging from 8-15 regarding Abuse and Resident to Resident altercations on the Homestead Unit on (MONTH) 2, 2019. No other resident to resident altercations were voiced by the residents. * Licensed Nurses completed skin assessment on 24 of 31 residents on Homestead identified with severe cognitive impairment to identify suspicion of Abuse and/or Neglect on the Homestead Unit. The skin assessments were completed (MONTH) 2, 2019. No concerns were identified. * The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) (2019) on the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations. Employees on leave of absence (FMLA), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires are educated on Abuse Prohibition policy during orientation. * The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. * Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure on (MONTH) 1, 2019. * Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156. |
2020-09-01 |