| 5 |
WASHINGTON CTR FOR AGING SVCS |
95014 |
2601 18TH STREET NE |
WASHINGTON |
DC |
20018 |
2019-07-30 |
610 |
L |
1 |
1 |
BMNI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to: thoroughly investigate an incident of abuse and/or neglect for Resident #164, implement measures to prevent potential abuse and/or neglect to other residents within the facility; and take appropriate corrective actions to keep other residents safe from possible abuse and/or neglect in one (1) of 56 sampled residents. The census on the first day of survey was 243. Findings included . On (MONTH) 23, 2019, at 11:09 AM an Immediate Jeopardy (IJ)-L was identified at 42 CFR 483.12 (c)(2)-(4), F610. On (MONTH) 25, 2019 at 3:13 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, as follows: The CNA identified in the complaint survey is no longer employed as of 7/16/2019. All residents were checked and three residents who are combative and/or exhibit combative behaviors were identified. Additional training was provided on the spot for those staff members on 7/22/2019. A meeting was conducted with the Administrator and the DON (Director of Nursing) on 7/23/2019 and 7/24/2019. Root cause analysis and investigation principles as it pertains to Abuse were addressed. All components of abuse were discussed including the interpretation of willful and its relationship to abuse. Abuse training and care of combative resident (training) was started on 7/21/2019 for all staff and is currently in progress. The managers will monitor the care of residents who are combative using the behavioral monitoring tool (see audit tools). The nurse managers and supervisors will continue to monitor the staff that provide care to residents who exhibit combative behaviors. Interventions will be implemented as indicated. The information will be provided to the DON who will provide this information to the QAPI committee quarterly and/or more frequently as indicated. Family request female: The Unit Manager received individual counseling and training on 7/23/2019. Unable to retrospectively correct the occurrence. All Unit Managers received training on 7/23/2019 and 7/24/2019 as it pertains to resident's rights, specifically their wish as it pertains to the caregiver. All Units were checked on 7/23/2019, via the nursing management team to determine if other residents had preference as it pertains to the sexuality of the caregiver. One resident was identified on 7/23/2019 and the Unit manager ensured that it was incorporated in the care plan on 7/23/2019. The Interdisciplinary team was re-educated on care planning and updating the care plan as the resident's conditions changes following detailed assessment of the resident on 7/23/2019. Upon admission and care plan meeting/conferences, the managers will determine the needs of the residents, specifically if a resident request a female and/or male care giver. The resident who expresses the female/male will be checked to ensure that this request was honored. This will be done via the assignment sheet every shift and reported to the QAPI (Quality Assurance and Performance Improvement) committee quarterly and/or more frequently as indicated. The nursing management audits the care plan monthly (see audit tool). When a care plan has not been updated the appropriate discipline is notified. This information is provided to the DON who presents this information to the QAPI committee quarterly and/or more frequently as necessary. In-service/Training: Training of the Administrator and DON regarding Root Cause Analysis and Investigation Principles as it pertains to Abuse (training completed on (MONTH) 24, 2019) Training of the Clinical Leadership Team (Training completed (MONTH) 19, 2019) Evidence of Abuse Training (Training for leadership, managers, and staff on abuse, residents with combative behaviors done on (MONTH) 19 2019- (MONTH) 24, 2019) Training on assignment of male/female CNA per resident's wishes (Training completed (MONTH) 24, 2019) The IJ was abated after the team verified that the plan of correction was in place on (MONTH) 25, 2019, at 4:07 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an F. Policy Title: Prohibition of Abuse; ADM01-003; Revised (MONTH) 2019 stipulates, [NAME] Stoddard Baptist Global Care, Inc. promotes the residents rights to be free from abuse, neglect, misappropriation of resident property and exploitation .No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection . Prevention: 4. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. Identification: .Because some cases of abuse are not directly observed, understanding resident outcomes of abuse could assist in identifying whether abuse is occurring or has occurred. Possible indicators include, but are not limited to: 1) an injury that is suspicious because the source of the injury is not observed or the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time. Investigation: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation. Protection: 1. In the interim of the investigation process, the alleged abuser may be suspended from work until an official notice is issued for clearance to return to work or otherwise by Human Resources. 6. Protection from retaliation. Reporting: .The results of all investigations are reported to the administrator or his or designated representative .and if the alleged violation is verified appropriate correction action must be taken. .2. Resident abuse is a ground for immediate termination refer to Employee Handbook. Employee Handbook revised (MONTH) (YEAR), page 5, stipulates, Abuse Prohibition policy: Actions of such may result in immediate termination . Record Review Review of Resident #164's medial record showed she was admitted to the facility on (MONTH) 29, (YEAR). The Quarterly Minimum Data Set (MDS) dated (MONTH) 3, 2019, under Section A1000 (Race/Ethnicity) the resident was coded as Asian, Native Hawaiian or other Pacific Islander. Under Section A1100 (Language) the resident was coded as needing and wanting an interpreter to communicate with a doctor or health care staff and preferred language Chinese. She was assessed with [REDACTED]. She was assessed as requiring extensive assistance of two (2) persons for bed mobility, transfers, dressing, toileting, personal hygiene and totally dependent for bathing under Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Further review of the record showed a nurse's note dated (MONTH) 16, 2019, at 12:30 PM: Writer was called by CNA (Certified Nursing Assistant/Employee #4) to come to resident room, when asked CNA said, He was trying to give care to resident when she became combative and in the process of turning, resident hit her head on the side rail of the bed. Happened at 11:35 am. Writer went and assessed resident and noted a swelling on her left face. Supervisors were informed. (Nurse Practitioner- Name) was called, who gave orders for resident to be transported via EMR (emergency response)/911. To the nearest ER (emergency room ). (Resident #164) is alert and unable to explain what happened. Her [DIAGNOSES REDACTED]. On assessment resident noted with swelling of the left fore head near the left eye with a cut on the left upper lip with minimal bleeding which was cleansed with normal saline. Ice pack applied to the left forehead swelling. V/S (vital signs) laying 138/69, P (pulse) 74, T (temperature) 97.7, Sp02 (peripheral capillary oxygen saturation) 98% on room air. V/S (vital signs) sitting B/P (blood pressure) 157/80, P 77, T (temperature) 98.2, R (respirations) 18. Pulse ox (oximetry) room air 97% FS (finger stick) 142 mg/dl (milligrams per deciliter). Tylenol 2 tabs 325 mg (milligrams) was administered for pain 4/10 and was very effective. Neuro (neurological) check initiated. RP (Responsible Party) made aware. Continued review of the record showed the (Hospital Name), computed tomography report dated (MONTH) 16, 2019, showed Resident #164 sustained trauma, Left periorbital soft tissue swelling. Associated displaced fracture lamina papyracea (orbital fracture). Minimal blood in the left ethmoid sinuses. Resident #164 was discharged from the facility on (MONTH) 26, 2019. Review of Employee #4's Personnel Record Review of Employee #4's statement dated (MONTH) 20, 2019 showed, Incident report on the 16th of June. I went into (Resident #164) room to clean her up, in the process of cleaning her, she became combative and hit her face on the bedrail which caused swelling on her face. So I decided to report the situation to the charge nurse immediately. I was not contacted on this during the week. Review of Employee #4's time card showed he arrived at work on (MONTH) 16, 2019 at 9:29 AM, punched out at 1:30 PM punched back in at 2:00 PM and punched out for the shift at 3:48 PM. The Personnel Report of Change dated (MONTH) 21, 2019 showed, the Employee #4 was suspended for three (3) days (6/21/19, 6/22/19, and 6/23/19). In-service records showed Employee #4 attended in-services on Prohibition of Resident Abuse and Neglect, Managing Resident with Dementia and Aggressive Behavior, Cultural Competency, and Resident Safety during ADL (activities of daily living) care on (MONTH) 25, 2019, (five days after the incident). The Personnel Report of Change dated (MONTH) 16, 2019 showed, the Employee #4 was terminated from the facility on (MONTH) 16, 2019. There was no evidence facility staff failed to immediately remove Employee #4 from the facility after the incident to ensure the safety of all residents, as evidence below: The incident occurred at approximately 11:35 AM on (MONTH) 16, 2019. According to the Employee's time card, he worked the duration of the shift (until 3:48 PM). There was no documentation of Employee #4's suspension until (MONTH) 21, 2019 (five days after the incident occurred. (The Employee did not work during this period.) On (MONTH) 27, 2019, Employee #4 was allowed to return to work, and assume his duties as a CN[NAME] Interviews: During a face-to-face interview with the Unit Manager (assigned to the unit of Resident #164) on (MONTH) 19, 2019, at 2:13 PM, she stated, I was the manager at the time of the incident with the CNA, it was a weekend on Sunday the supervisor called me there was an incident that occurred on your floor and we called 911. The CNA take took care of her an abrasion during care, the face is swollen and we put on ice packs we have to send her out 911. I do not know why Employee #4 was taking care of her because the family requested that they did not have a male they told this to me. The family requested to have another (Employee Name) and that weekend she was off. Employee # 4 knew he was not supposed to take care of the resident. Employee #4 came in late and the other CNA switched (the resident assignment) .the charge nurse did not know that he switched the resident (assignment). She (the resident) is always is agitated . The surveyor asked, What do you do when a family make a request regarding patient care? Most of the time we have an in-service to let them know what the family is requesting. I care plan it so everyone will know /they are well-informed so that the message is passed on . Resident #1 is an unusual incident I don't tolerate abuse, why should I want to be abused, this is something I will regret. During a face-to-face interview with Employees' #1 and #2 on (MONTH) 19, 2019 they stated, We conducted the investigation of (Resident #1). He (Employee # 4) was the only person involved in the incident. There were no witnesses. The Employee was suspended immediately. He was sent for education/in-services and returned to work on (MONTH) 27, 2019 at 7:28 AM. We believe what he (Employee #4) said about what happened. He probably could have called for additional help. We maintain the actions of Employee #1 (CNA) were not abusive (willful) but a care issue. We still believe it's a care issue. The writer asked, is it my understanding that the Resident only wanted female CNAs? Employees' #1 and #2 stated, The unit manager got the note (from the family), the note was received before this incident requesting that the resident (Resident #164) not have a male CN[NAME] The writer asked, what was the outcome of the investigation? Employees' #1 and #2 stated, The Employee needed further education on combative residents and dignity and monitoring during care. The writer asked, how were they monitoring Employee #4? Employees' #1 and #2 stated, They were asking the charge nurses how the employee was doing. The monitoring started immediately (upon his return to work on (MONTH) 27, 2019). There was no monitoring tool. They would touch basis on the days he worked to ensure he was fine. The writer asked, why was the Employee terminated on (MONTH) 16, 2019? Employee #1, stated, he was terminated on (MONTH) 16, 2019, as a result of the DC Department of Health Complaint Investigation Report (C-19-057, DC-4819, harm level deficiency cited), gross negligence, carelessness, failure to follow the policy and procedure in the care of a resident. We could have done better. Summary of Findings: The facility failed to provide an interpreter to communicate with the resident while providing health care services (ADL care) Per the MDS dated (MONTH) 3, 2019. The facility failed to provide two (2) person physical assistant when performing adl care for Resident #4 on (MONTH) 16, 2019, Per the MDS dated (MONTH) 3, 2019. The facility staff failed to ask why Resident #164's family did not want male CNAs caring for the resident. The facility staff failed to have written documentation that staff were in-serviced on the family's wishes not to have male CNAs care for Resident #164. The facility CNA staff failed to follow their resident care assignments given by the Charge Nurse on (MONTH) 16, 2019. Employee #4 (CNA) failed to stop caring for Resident #164 who became combative during ADL care on (MONTH) 16, 2019. Employee #4 failed to call for assistance when Resident #164 became combative on (MONTH) 16, 2019. The facility's investigation lacked evidence such as, the supervisor's written account of what occurred and how Employee #4 was supervised/managed after the incident, and a written statement from Employee #4 at the time of the incident stating what occurred during care of the resident. There was no formal written summary/conclusion of the facility's investigation. The facility administrative staff failed to thoroughly investigate and recognize the incident on (MONTH) 16, 2019 as a likelihood of abuse or neglect. The administrative staff, however, identified the incident on (MONTH) 16, 2019 as a care issue. The facility's administration received the survey findings from the (DC Department of Health) complaint report, and as a result of the findings Employee #4 was terminated on (MONTH) 16, 2019 for gross negligence, carelessness, and failure to follow the policy and procedure in the care of a resident. Employee #4 worked 33 hours providing care to other residents from (MONTH) 27, 2019 to (MONTH) 16, 2019, prior to being terminated. During the face-to-face interview on (MONTH) 23, 2019 approximately at 2:15 PM, Employees' #1 and #2 acknowledged the findings. |
2020-09-01 |