| 6524 |
THE TERRACES OF PHOENIX |
35003 |
7550 NORTH 16TH STREET |
PHOENIX |
AZ |
85020 |
2012-01-05 |
226 |
D |
1 |
1 |
GVCP11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility investigations, staff and resident interviews, and review of facility policy, the facility failed to implement their abuse policy regarding investigations of abuse for two residents (#s 20 and 42), and failed to train facility staff in reporting abuse in a timely manner. The allegatiosn were unable to be substantiated. The sample size was four residents. Findings include: -Resident #20 was readmitted to the facility March 12, 2011, with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE], coded the resident as cognitively independent without memory problems. During the night shift on November 25, 2011, resident #20 called to be assisted to the bathroom. She alleged that when staff #1 and #2 came into her room, that they asked the resident why she did not wait for the male certified nursing assistant (CNA), to which the resident replied that she had to go to the bathroom now. She also alleged that during the toileting, one of the CNAs (she did not know which) asked her if she had ever had her tongue around a black man's sausage, to which the resident replied no, and that she did not appreciate that kind of language. The incident was reported to the day shift administrative staff, and the facility investigation was provided to the State Agency within the required time limits. A review of additional facility documentation included all the information that had been faxed to the State agency, as well as personnel information, and information related to the facility reporting the CNAs to the State Board of Nursing. The investigation included interviews with the two CNAs accused, another CNA and a licensed practical nurse who were working on the night shift the night the incident occurred, and who spoke to the resident about the incident. Further review of the investigational documentation did not include that any alert and oriented residents were interviewed to determine if they had experienced any verbal or other abuse from the CNAs. The CNAs were suspended then terminated. A brief interview with resident #20, conducted January 4, 2012, included that she agreed the information obtained by the facility regarding her recollection of events was accurate. During an interview conducted January 4, 2012 at 2:00 p.m., the director of nursing (DON) stated that this incident was kind of traumatic for the facility, and that she hated to terminate the two CNAs, but she did not have any choice. She also stated that the CNAs both denied making any such statements to the resident, and stated that they would never speak like that to any resident. She suspected that there may have been some "horseplay" going on, i.e. that the CNAs were talking to each other, not the resident, but if that happened, it was still inappropriate and grounds for termination. The DON could not explain why no other resident interviews were conducted, but acknowledged that none had been done. -Resident #42 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of the facility self-report dated November 30, 2011, regarding staff to resident abuse revealed a lack of documentation regarding interviews with other residents with whom the staff member had also provided care. The report further revealed that the alleged abused occurred on November 25, 2011, at 9:30 PM, however the CNA who witnessed the incident did not report the alleged abuse to the director of nursing until November 29, 2011. An interview conducted with the DON and the administrator stated that the only resident interviewed during the investigation was the same one which the alleged that abuse occurred. The DON and administrator revealed that other residents that received care and services from the alleged perpetrator were never interviewed. They further stated that the CNA that witnessed the abuse failed to report the incident because it was a holiday weekend. An interview with the CNA who witnessed the abuse stated that he planned on reporting the abuse to the director of nursing when the weekend was over. A review of the facility policy on abuse revealed, "...All reports of resident abuse, neglect, injuries of an unknown source, resident to resident abuse and resident to staff abuse abuse are promptly and throughly investigated by facility management...Interview other residents to whom the accused employee provides care or services to determine if they have complaints about the employee..." |
2015-08-01 |