| 16 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2018-12-06 |
600 |
G |
1 |
1 |
H65F11 |
> Based on record review, observations, and review of other facility documentation as indicated, it was determined that for 2 (R31 and R52) out of 54 sampled residents, the facility failed to ensure that residents were free from abuse. For R31, the facility failed to ensure R31 was free from potential physical, emotional and verbal abuse and for R52, the facility failed to ensure R52 was free from actual physical, emotional and verbal abuse from resident to resident altercations. For R31, another resident in the same hallway (R15), has wandered into R31's room during the night which has the potential for abuse. R52, who resides in the same hall as R31 and R15, has been emotionally, verbally and physically abused by R15 as evidenced by cursing, yelling, hurtful remarks, hitting, and being accused of things. As a result of this abuse, R52 has experienced feeling fearful, upset, sad, anxious, and at times, R52 isolates herself in her room to avoid R15. This is a harm level deficiency for R52. Findings include: Review of the facility policy entitled Abuse, Neglect, Mistreatment, Misappropriation, and Exploitation, effective (MONTH) (YEAR), stated, . Purpose: To ensure that all patients and residents will be free from abuse, neglect, mistreatment, misappropriation and exploitation of funds and resources . a. Physical abuse by unnecessarily inflicting pain or injury to a patient or resident. This includes but is not limited to, hitting, kicking, punching, slapping, pulling hair, or corporal punishment of any kind . c. Emotional Abuse which includes, but is not limited to, ridiculing, demeaning, humiliating, or cursing at a patient or resident , or threatening a patient or resident with physical harm Staff Responsibilities . b. If an act of abuse, neglect, mistreatment or property misappropriation is witnessed, the witness must act to first remove the source of the act, whether it is a staff member or a visitor, and then take steps to protect the resident . 1. Review of R52's clinical record revealed the following: R52 was admitted to the facility in (YEAR). A quarterly MDS assessment, dated 10/4/18, coded R52 on a scale of 0-15, with 0 being never/rarely made decisions and 15 being the highest level of cognition (decisions consistent/reasonable), as a 15. Review of an incident report for R52, dated 11/25/18 and timed 3:30 PM, stated, Resident involved in incident with another Resident (R15) in which she was slapped on right arm . Resident (R15) noted verbally aggressive/physically aggressive towards another Resident (R52). The incident occurred in the lounge near the nurses station. Review of a CNA statement on 11/25/18 and timed 3:30 PM, stated, I witnessed (R15) come out of her room yelling at (R52). I walked over as she (R15) was hitting (R52) (she (R15) smacked her (R52) on her arm once). A progress note, dated 11/25/18 and timed 5:05 PM, was written for R15 (the resident involved in the incident) and it was included in the incident report. The progress note, written by a nurse, stated, At approx. (approximately) 1530 (3:30 PM), resident (R15) noted standing in lounge area, agitated while shouting 'you stole my money' headed towards another resident (R52). CNA approached (R15) and (sic) a very calm therapeutic manner, however resident continued to be verbally aggressive (towards other resident) and quickly slapped the resident's left (sic) arm. Attempts to redirect made, resident (R15) escorted to her room . remains A&OX1 (alert to person only, not to place or time); to self, per established baseline. Nursing staff to monitor . A progress note, dated 11/25/18 and timed 5:05 PM, stated, At approximately 1530 (3:30 PM) (R52) was involved in an incident with another resident (R15). Another resident became verbally aggressive towards (R52), and quickly slapped her on the right arm. (R52) was removed from scene immediately, and assessed by Nurse . Resident stated, 'I don't know why she did that', when asked if she knew anything that could have contributed to the incident . There was no obvious injury to R52's arm. R52 was interviewed by the state surveyor on 11/28/18 at 9:15 AM. R52 expressed that R15, who resides down the hall a few doors from her room curses and hits her. When asked how long this has been going on, R52 stated since she (R52) has been in the facility for 3+ years. R52 stated that R15 slapped her in the face previously, but has not caused her bodily injury. R52 further stated that R15 has accused her (R52) of stealing R15's money and buying clothes. R52 stated that she was not the only person R15 abuses and stated when R15 walks down the hall, she'll use her walker to hit anyone in her way. R52 stated that if she see's R15 in the hall where they reside, she'll go into her room, close the door and turn down the television sound so she (R15) won't know I'm there. R52 stated that staff have observed these behaviors from R15 and advised her not to hit R15 back, however, she stated, I'd really like to hit her back. When asked if she's talked to staff about her concerns regarding R15, R52 stated that she talked to E1 (NHA) a few days ago and was told that they'd try to remove sitting chairs in the hall so if R15 sits, it will be in the area by the nurses station. E52 became tearful several times when discussing R15 and stated I don't even look in her (R15's) room when I walk by and the CNA's are afraid of her. When asked how all this makes her feel, R52 stated, I can't take it anymore. I feel terrible, it upsets me. Sometimes I feel like pulling my hair out by it's roots. R52 also stated that she didn't want to have a nervous breakdown . I don't want to have . one because of her (R15). R52 denied any further incidents with R15 throughout the survey from 11/28/18- 12/6/18. Record review revealed that R52 has received counseling from a psychologist (E15) on an ongoing basis since at least (MONTH) (YEAR). On 11/28/18 at 11:43 AM, R52 was seen by E15. R52's mood was described as depressed and anxious. The progress notes stated, . Pt (patient) discussed how she had an altercation with another resident and how the situation is being handled . Psychologist provided supportive and empathetic listening and feedback to pt(patient) . A progress note, dated 11/28/18 and timed 4:32 PM, was written by E2 (DON). The note stated, . Spoke with resident after interaction on 11/25/18. Resident states she feels much better today and that she slept 'like a baby' last night. Resident states she has felt comfortable on the unit and continues to sit and converse with peers . AAO x 3 (alert and oriented to person, place and time). Verbally able to make needs known. Continues to attend the dinning (sic) room for meals with good appetite . right arm . no marks or bruises . denies pain . Continues to self propel w/c (wheel chair) on and off unit without difficulty . Continues to participate in activities. A progress note, dated 11/28/18 and timed 5:51 PM, written by E2, stated, Spoke to resident daughter regarding resident status. Daughter pleased to hear resident doing well. Will continue to monitor. The 5 day follow up, written by E2 (DON), was submitted to the state agency on 11/30/18 for the 11/25/18 incident. The follow up stated, . Spoke with (R52) on 11/26 and 11/28 following interaction on 11/25. (R52) remains AAOx 3. Verbally able to make needs known . Seen by psychologist with no further interventions necessary. Resident (R15) with no further episodes of physical aggression towards other residents. Has dx (diagnosis) depression, pseudobulbar affect (neurological condition characterized with uncontrollable laughing and crying) and dementia. Has known behaviors related to physical aggression and receives counseling. Continues to ambulate (walk) on unit with RW (rolling walker) . ADON spoke with resident regarding programing on the dementia unit and potential benefits. Family in agreement to trail (sic- trial) unit during day before making a decision. R52 stated that R15 had not bothered her during the survey period of 11/28/18 through 12/6/18. On 12/5/18 at 2:35 PM, findings were discussed with E2 (DON) and she was advised that this was a harm level deficiency. The facility failed protect R52 from emotional, verbal and physical abuse from R15. R15 has a history of physical aggression towards staff and other residents, verbal aggression including yelling and cursing at staff and other residents, and false beliefs/accusations, including that someone stole her money and other belongings. R52, who is cognitively intact, stated that R15 curses at her, says hurtful things to her, and hits her, even going out of her way to do so, at times. R52 was most recently hit by R15 on 11/25/18. As a result of R15's behaviors towards R52, R52 stated that she secludes herself in her room when she see's R15 in the hall (both reside in same hall) by shutting her bedroom door and turning down the volume on her tv so R15 won't know R52's in her room. R52 also reported that she feels sad, upset and afraid due to R15's abuse. R52 stated that she doesn't want to have a nervous breakdown because of R15. 2. Review of R31's clinical record revealed the following: R31 was admitted to the facility in 2014. Review of a quarterly MDS assessment, dated 9/13/18, coded R31 on a scale of 0-15, with 0 being never/rarely made decisions and 15 being the highest level of cognition (decisions consistent/reasonable), as a 15. R31 was interviewed by the state surveyor on 11/28/18 at 9:58 AM. R31 stated that R15 wandered into his room last night about 2:00 AM and she was asking where someone was. R31 further stated, I feel like she doesn't belong on this floor, but family doesn't want her to go to 3rd floor. R31 further stated this was not the first time R15 had done this, but it's the first time in awhile. R31 stated that his roommate likes the door open, so R15 see's it open and wanders in. Findings were reviewed with E2 (DON) on 12/5/18 at 2:35 PM and advised this has the potential for harm. The facility failed to ensure R31 was free from potential abuse when R15 wandered into R31's room due to lack of adequate monitoring and supervision on 11/28/18 at approximately 2:00 AM. R15 has a history of distressed behaviors, including verbal and physical abuse of staff and other residents. R31 stated that R15 had wandered into his room previously, too. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E14 (RN/QA) on 12/6/18 at approximately 7:45 PM during the exit conference. |
2020-09-01 |