| 62 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2019-03-02 |
610 |
J |
1 |
0 |
KDKT11 |
> Based on interviews and review of the facility's policy titled OPS300 Abuse Prohibition, the facility failed to immedately investigate an allegation of physical abuse perpetrated by Resident Identifier (RI) #1, a cognitively impaired resident who resides on the facility's Homestead Memory Care (Dementia) Unit. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the Director of Nursing Service (DNS); however, she was told to not document anything that the DNS, would take care of everything in the morning. There was no documentation or investigation of this allegation of physical abuse until 2/27/2019. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who reside on the facility's Homestead Memory Care (Dementia) Unit. 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, F610. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation will be thoroughly documented within RMS (Risk Management System). Ensure that documentation of witnessed interviews is included. 6.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. 6.8.2 Enter a summary of the interviews into RMS. 6.8.3 Interview forms will be kept confidential in a file in the administrative office . In an interview with Employee Identifier (EI) #1, the Center Executive Director, also known as the Administrator, on 2/28/2019 at 12:25 PM, he was asked what he expected the staff to do when they became aware of the incident. EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have been completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. According to the facility's investigative summary submitted to the Alabama State Survey Agency dated 3/5/2019, documented . Allegation Summary. On (MONTH) 27, 2019, in the course of an Abbreviated Complaint Surrey by the Alabama Department of Public Health, the Center Executive Director (Abuse Prevention Coordinator) was notified that during the 2-10p shift of (MONTH) 20, 2019, an alleged resident-to-resident altercation occurred between (RI #1) and (RI #2) . Center Findings . * There was no . documentation in the record; or, investigation of the allegation until (MONTH) 27, 2019 . ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F610, which documented: F-610 J-Investigate/Prevent/Correct Alleged Violation Licensed Nurse discharged RI #1 to Baptist Senior Care Unit 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. Center Executive Director initiated an investigation on (MONTH) 27, 2019 related to the resident to resident altercation on (MONTH) 20, 2019. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the Abuse Prohibition policy and procedure to include investigation of incidents. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy related to investigating incidents 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 to include investigation of incidents 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 F610 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 |