cms_GA: 154
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 154 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2018-05-02 | 600 | D | 0 | 1 | 04GG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, and staff interviews, review of the facility's Abuse Prohibition Policy and Procedure revised, 12/17, The facility failed to ensure that an allegation of verbal/mental abuse was reported to the State Agency (SA) and that a thorough investigation related to the allegation of verbal/mental abuse was done for one resident (R#74). Findings Include: Review of the Abuse Prohibition Policy and Procedure revealed that Abuse is also defined as any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including, but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend d, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident such as telling a resident that she will never be able to see her family again. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Investigation: Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: 1. The description of the alleged complaint. 2. Information gathering. 3. Document the description of the injury. 4. Interviews will be conducted of all pertinent parties. 5. Past performances and/or previous incidents. 6. Describe actions taken by facility to protect resident. 7. All investigation information will be kept on file in a secured location. Record review for R#74 revealed the resident was admitted to the facility on [DATE], with diagnoses, including but not limited to cerebral infarction, localized [MEDICAL CONDITION], chronic pai[DIAGNOSES REDACTED], autonomic [MEDICAL CONDITION] in diseases classified elsewhere, [MEDICAL CONDITION] following cerebral infarction, flaccid [MEDICAL CONDITION] affecting right dominant side, other recurrent [MEDICAL CONDITION], anxiety, [MEDICAL CONDITIONS], diabetes mellitus. Review of the 4/14/18 Quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15 which indicates that the resident was moderately cognitively impaired. Further review of Section G revealed total dependent for bed mobility with full staff performance at one time, two staff assist, bed transfer two person assist. During interview with R#74 on 4/30/18 at 12:00 p.m., in the resident's room, revealed that she had a nurse talk in an inappropriate manner to her. Resident stated her daughter would be there soon and ask that I speak with her because the stroke she had affects her ability to talk clearly. On 4/30/18 at 12:30 p.m. R #74's daughter requested the surveyor to speak with her with her Mom present. Upon entering the room R #74's roommate was not in the room and at the daughter request the door was shut to allow a private conversation. Daughter states that on Monday of the previous week her Mom was having a lot of pain and had refused her shower. She states a nurse told R #74 that if she didn't take a shower she would pick her up and throw her in the shower and this upset R #74 and she told the nurse she was not taking a shower because she was in a lot of pain and having a bad day. Daughter then stated that the nurse said, If you don't take a shower you will not get any more pain medication. Daughter states she called in a complaint to the Ombudsman who said she would get back with her but states she hasn't heard from her yet. Also states that she complained to the head nurse. During the interview R #74 would shake her head in agreeance to everything her daughter was telling me. R #74 stated that the nurse was joking but it was not funny. Interview with Social Services (SS) on 4/30/18 at 1:00 p.m. revealed that the Ombudsman had left her a message to return her call earlier in the week but did not actually speak with her until late in the day on 4/26/18. SS states that the Ombudsman told her that R #74's daughter called stating a nurse told her Mom if she didn't get a shower she would throw her in the shower and something else about not giving her any pain medicine. She stated that the Ombudsman said she was confused about the whole thing. States that the daughter of R #74 said she reported this to a person who has been gone from the facility since (MONTH) (YEAR). SS stated she went immediately and interviewed the resident and then spoke with the Director of Nursing ( DON) and the Administrator regarding the Ombudsman's call and the allegation that was made. Interview with DON and Administrator on 4/30/18 at 1:20 p.m. revealed that SS came to them on 4/26/18 and advised them that the Ombudsman had called her regarding a complaint but stated the Ombudsman was confused about what the daughter told her. The Administrator stated that a grievance/complaint is in process. The alleged abuse by the daughter and R #74 to the surveyor was reported to the Administrator and DON. During a telephone interview on 4/30/18 at 1:40 p.m. with R #74's daughter revealed that her Dad gave her the name of the head nurse and she didn't realize she had the wrong name but states her office is located just inside the rehab department, immediately to the left. She states there is a small hall and her office is at the end. Interview with DON, in her office on 4/30/18 at 2:00 p.m. revealed that she states she did not have a conversation with R #74's daughter. When asked if she had just had her hair done and highlighted recently she asked, How did you know that? I stated because when I called R #74's daughter to discuss the name of the person she had reported this incident to at the facility had not been there since (MONTH) of (YEAR) she stated that her Dad told her that was the name but then the daughter gave specific directions to the DON office and said she remembered specifically because she complimented her on her hair just being done and highlighted. The DON again stated that she had never spoken with R #74's daughter about this incident. During a telephone interview with Ombudsman on 5/1/18 at 11:45 a.m. revealed that she spoke with SS at the facility on 4/26/18 between 12:30 p.m. and 1:30 p.m. She stated she was under the impression the DON and Administrator had already worked their notice and left so she spoke with SS and informed her that R #74's daughter called her alleging that a nurse threated to throw her Mom in the shower after refusing to take one and that she would not get any more pain medication if she didn't take a shower. Ombudsman states SS told her that the person in the facility R #74's daughter said she spoke with has been gone since (MONTH) (YEAR). I explained to the Ombudsman the daughter stated to me that she had gotten her information from her Dad and the Ombudsman stated, Then that is where the confusion came in. I explained how the daughter described in detail how to get to the DON's office and the compliment the daughter states she made to the DON about her hair. Also explained how I interviewed with the DON after speaking on the phone with the daughter and that the DON states she never spoke with R #74's daughter. On 5/1/18 at 2:00 p.m. during an interview with DON, Administrator, and SS revealed that SS believes, if the allegation is true, that what took place between the nurse and R #74 is verbal abuse. Administrator was asked if this has been reported to the State Agency and he states it has not been reported because the Ombudsman was involved and SS spoke with the resident and she denied it, so he didn't see the need to report it to the State Agency. DON states she did not know anything about a nurse threatening to throw R# 74 in a shower until Monday when it was reported to her by the Surveyor. She also states that the only thing SS said to her was that the resident told her that a nurse threatened to withhold her pain medication because she didn't take her [MEDICATION NAME] that morning. SS states that she did inform both the Administrator and DON about the call from the Ombudsman. DON states, But you did not say anything about the nurse threatening to throw her in the shower. I went back to my notes and reminded SS of our conversation on 4/30/18 at 1:00 p.m. in her office and that she stated that the Ombudsman told her that R #74's daughter called stating a nurse told her Mom if she didn't get a shower she would throw her in the shower and not give her any pain medicine. SS then stated that the Ombudsman told her she herself was confused about the whole thing. On 5/1/18 at 5:40 p.m. during a telephone interview with alleged LPN (Nurse) revealed that she does sometimes cut up with the residents but she doesn't know for sure if she said she would throw R #74 in the shower. She states she did not tell the resident she would not give her pain medication if she didn't get in the shower. States the resident ask for a pain pill and she told her that she couldn't have a pain pill because she didn't take her [MEDICATION NAME]. When ask why she couldn't have a pain pill just because she refused her [MEDICATION NAME] the nurse stated it was because she was wheezing and having a hard time breathing and she needed the [MEDICATION NAME]. On 5/2/18 2:45 at p.m.during interview with the Administrator and DON revealed that the Administrator did not report the Allegation because the Ombudsman was involved already. Administrator was given a copy of the regulation regarding reporting allegations of abuse to the State Agency within 2 hours if there is injury, and within 24 hours if there is no injury. He states he understands and has a book where he has reported many things to the State Agency but he thought since the Ombudsman was involved there was no need to report it to the State Agency. States once he receives an allegation of abuse, the resident's safety is priority and maintained, it is reported to the State Agency, and an investigation is started. Complaint Form dated 4/26/18 revealed that SS, received a complaint from R #74 that a couple of days ago before lunch she asked for a pain pill from her nurse and the nurse told her no because she refused her [MEDICATION NAME] but then she returned an hour later with her pain pill. | 2020-09-01 |