| 77 |
DESERT HAVEN CARE CENTER |
35062 |
2645 EAST THOMAS ROAD |
PHOENIX |
AZ |
85016 |
2020-01-08 |
609 |
D |
1 |
0 |
DWKV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of policies and procedures, and review of the State Agency data base, the facility failed to ensure that alleged violations involving abuse or mistreatment for [REDACTED].#1, 2, 3, 4) were reported to APS (Adult Protective Services) and failed to ensure that the results of investigation of alleged violations involving abuse or mistreatment for [REDACTED].#1, 3, 4, 5) were reported to the State Agency. The deficient practice could result in additional allegations of abuse or mistreatment not being reported to APS, and additional results of investigations of abuse or mistreatment not being reported to the State Agency. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #5 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 9, 2019 included that resident #5 had a BIMS score of 7 which indicated that resident #5 had severe cognitive impairment. The assessment included that resident #5 had verbal and physical behavioral symptoms directed towards others, no functional limitations in range of motion and used a wheelchair. An Incident Note dated (MONTH) 15, 2019 at 11:34 p.m. included that during a smoke break, resident #5 had grabbed all of the cigarettes, which caused an argument with a peer. The note included that resident #5 grabbed the peer by her sweater, which caused the peer to slide to the floor, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 15, 2019 at 7:10 p.m. as residents were headed to a smoke break, and when resident #1 noticed that resident #5 had the box of (resident) cigarettes, resident #1 became angry and confronted resident #5, and resident #5 grabbed the sweater of resident #1. The report included that when resident #5 grabbed the sweater of resident #1, this caused resident #1 to fall to the ground. The report included that the AZDHS (Arizona Department of Health Services), Phoenix Police, local Ombudsman and responsible parties were notified of the incident. Review of the facility investigation did not reveal a fax receipt, and review of the State Agency data base did not reveal any documented evidence that the facility sent a summary report of the incident on (MONTH) 15, 2019 to AZDHS. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 said that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. resident #1 entered resident #2's room and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. Staff separated the resident's and there were no injuries. The report included that the AZDHS (Arizona Department of Health Services), Phoenix Police, local Ombudsman and responsible parties were notified. However, there was no documentation that APS had been notified of the incident on (MONTH) 21, 2019. Review of the facility investigation revealed a form titled Desert Haven Care Center State Report File Folder. The form included multiple entries where staff recorded that the incident was reported on (MONTH) 21, 2019 to AZDHS, the Phoenix PD (Police Department), the resident's responsible party, and the State Ombudsman. However, the form did not include a space to record that APS had been notified of the incident. -Resident #4 was admitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. An Admission MDS assessment dated (MONTH) 20, 2019 included that resident #4 had a BIMS score of 3, which indicated that the resident had severely impaired cognition, difficulty focusing attention and physical behaviors directed at others. An Incident Note dated (MONTH) 7, 2019 at 10:36 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. -Resident #3 was admitted on (MONTH) 6, 2014 with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated (MONTH) 9, 2019 included that the resident had speech that was unclear or slurred, and that he usually understands others. The assessment included that the resident had a BIMS score of 9, which indicated that the resident had moderately impaired cognition, and verbal behavioral symptoms directed at others. An Incident Note dated (MONTH) 17, 2019 at 10:31 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 17, 2019 residents #4 and #3 were in the unit dining room, and began to have a verbal altercation, and that resident #4 reached over and hit resident #3 on the right arm. The report included that the residents were immediately separated and there were no injuries. Review of the facility investigation revealed a State Report File Folder form, which included that the incident was reported on (MONTH) 17, 2019 to AZDHS, the Phoenix PD (Police Department), the resident's responsible party, and the State Ombudsman. However, there was no documentation on the form that APS had been notified of the incident. Also, review of the facility investigation did not reveal a fax receipt, and review of the State Agency data base did not reveal any documented evidence that the facility sent a summary report of the incident to AZDHS. The following interviews were interviews conducted on (MONTH) 6, 2020 with the Director of Nursing/staff #120: -At 1:45 p.m. the Director stated that he tries to save fax receipts when he sends the 5 day summary report of the investigation to AZDHS. However, the fax machine had broken down and he was unable to print fax receipts. The Director also stated that the facility does report allegations of abuse to APS, and notifications to APS are sometimes done by the nurse on duty. However, the Director examined the Report File Folder forms, and stated that APS was not listed on the form to be notified of an allegation, which may have resulted in the nurse not notifying APS. -At 2:25 p.m. the Director stated that he had phoned APS to determine if APS had received reports of the incidents on (MONTH) 17, 2019 and (MONTH) 21, 2019, and stated that APS had never received notification of the incidents A policy and procedure titled Abuse Investigations included a statement that all allegations/signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The policy included that the Administrator of designee will review and if incidents meet the elements of reporting within 2 hours, will ensure appropriate Regulatory Agencies, Law enforcement, Medical Director and Representative are notified. The policy also included that the Administrator or designee will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the Ombudsman and others as may be required by State or local laws, within 5 days of the incident. |
2020-09-01 |