| 80 |
HATLEY HEALTH CARE INC |
15023 |
300 MEDICAL CENTER DRIVE |
CLANTON |
AL |
35045 |
2019-05-09 |
609 |
D |
1 |
1 |
HQGM11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record reviews, review of facility policies titled, ABUSE, NEGLECT AND EXPLOITATION and REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION and review of a document titled, Alabama Department of Public Health Online Incident Reporting System, the facility failed to timely report 13 allegations of abuse to the State Agency after the incidents occurred. This affected 14 of 71 facility reported incidents that were reviewed and affected Resident Identifier's (RI) #434, #74, #79, #47, #8, #69, #115, #22, #21, #104, #46, #38, #109, #70 and two unsampled, discharged residents. Findings Include: A review of the facility policy titled ABUSE, NEGLECT AND EXPLOITATION, with no date, revealed the following: .The facility must: .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, . A review of the facility's policy titled, REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION, with no date, documented: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations. Review of the Alabama Department of Public Health Online Incident Reporting System, revealed the following: 1) An incident of mistreatment was reported by a Certified Nursing Assistant (CNA), regarding another CNA being abnormally rough with Resident Identifier (RI) #434 on 04/25/2019 at 10:30 AM. This incident was not reported to the State Agency until 04/25/2019 at 3:29 PM. 2) An incident of verbal abuse was reported occurring on 01/12/2019 at 6:57 PM where RI #79 was fussing at other residents and staff and RI #74 threatened to kill RI #79. This incident was not reported to the State Agency until 01/14/2019 at 8:04 AM. 3) An incident of physical abuse was reported occurring on 01/08/2019 at 10:00 AM where RI #47 reported that a CNA, was rough and jerked RI #47 in the bathroom. This incident was not reported to the State Agency until 01/09/19 at 1:37 PM. 4) An incident of physical abuse was reported occurring when RI #8 reported that a CNA, was rough when giving a shower on 11/22/2018 at 5:00 p.m. This incident was not reported to the State Agency until 11/23/2018 at 10:02 AM. 5) An incident of physical abuse was reported occurring on 10/31/18 at 5:54 PM where RI #115 hit RI #69 on the shoulder and RI #69 pushed RI #115 onto the bed. This incident was not reported to the State Agency until 11/01/18 at 7:22 AM. 6) An incident of neglect was reported occurring on 10/31/18 at 6:00 PM where a CNA, refused to change RI #22 and talked hateful to RI #22. This incident was not reported to the State Agency until 11/01/18 at 9:02 AM. 7) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #104 stated that RI #21 grabbed and bent his/her hand back. This incident was not reported to the State Agency until 10/31/18 at 7:36 AM. 8) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #115 went up to RI #79 and started slapping RI #79's hands. This incident was not reported to the State Agency until 10/31/18 at 7:47 AM. 9) An incident of physical abuse was reported occurring on 10/27/18 at 5:00 PM where RI #115 walked into RI #46's room and hit RI #46 on the left shoulder. This incident was not reported to the State Agency until 10/29/18 at 7:08 AM. 10) An incident of physical abuse was reported occurring on 10/23/18 at 12:00 AM where RI #38 went into RI #46's room and RI #46 twisted RI #38's arm. This incident was not reported to the State Agency until 10/25/18 at 4:27 PM. 11) An incident of physical abuse was reported occurring on 09/16/18 at 8:45 AM where RI #79 came around the corner of the nurse's station where RI #109 was sitting in a wheelchair and RI #109 kicked RI #79's wheelchair and RI #79 grabbed RI #109's lower leg and squeezed it. This incident was not reported to the State Agency until 09/16/18 at 2:31 PM. 12) an incident of physical abuse on 09/10/18 at 1:15 PM where a unsampled, discharged resident came in to the activity room and tapped RI #70 on the arm and told RI #70 to move because it was his/her spot. This incident was not reported until 09/12/18 at 1:43 PM, 13) An incident of injuries of unknown source was identified on 08/28/18 at 9:30 PM when RI #88 was noted to be guarding his/her right arm per EI #12, Licensed Practical Nurse (LPN), and xrays revealed a [MEDICAL CONDITION] distal humerus and elbow joint. The incident was not reported to the State Agency until 08/29/18 at 12:26 PM. 14) An incident of physical abuse was reported occurring on 07/14/18 at 10:00 PM where another unsampled, discharged resident complained that RI #69 (spouse) was hitting him/her in the chest. This incident was not reported to the State Agency until 07/15/18 at 6:16 AM. On 05/09/19 at 2:45 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Assistant Director of Nursing (ADON)Abuse Coordinator. EI #2 was asked, when should an allegation of abuse be reported to the State Agency. EI #2 said within two hours. EI #2 was then asked to individually review the 14 incidents listed and asked whether they were reported to the State Agency within the designated two hour time frame. EI #2 answered no, to all 14 incidents and explained that some of the incidents had been slid underneath her office door and she found them on her return to work. She further stated that she had found one of the incidents written on a 24 hour report form. On 05/09/19 at 4:08 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked if he had been made aware of the facility not reporting incidents timely to the State Agency. EI #1 said yes. EI #1 was asked what was the reason identified for the reports being submitted late. EI #1 stated they had been doing education with the employees identified for not reporting timely and that all employees receive abuse training twice a year. This citation resulted from the investigation of complaint/report # AL 246. |
2020-09-01 |