cms_GA: 3906
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3906 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 610 | J | 0 | 1 | XS0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility investigations, it was determined the facility failed to thoroughly investigate the 12/18/18 incident where R#121 was subjected to a painful urinary catheter insertion and verbal threats. The facility failed to develop preventive measures in place to ensure no other vulnerable residents experience abuse from the same nurse. This failure resulted in the 12/23/18 incident in which R#55 was subject painful removal of stool by the same nurse. The sample size was 57. This deficient practice created the potential that abuse would go unrecognized, not addressed, and perpetuate a culture in which abuse could occur. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: 1. An interview was conducted with R#121's family on 1/7/19 at 10:00 a.m. during the initial resident pool selection. The family expressed concerns related to LPN II that is currently employed by the facility. The family stated they had reported an incident that occurred on 12/18/18 to the Director of Nursing (DON) involving LPN II attempting at least six times to insert a urinary catheter into the resident while the resident was screaming. They requested the nurse no longer take care of R#121. Although this occurred, LPN II continues to work at the facility on the same unit. Interview with the DON and Administrator on 1/7/19 at 3:30 p.m. revealed when asked if they were aware of the allegation from R#121's family? They both stated, Yes, they were aware of it. They were asked if it had been investigated and if there was any documentation of the investigation? The DON stated she had investigated it and the Administrator and the DON agreed they thought it was a personality conflict between the family and the nurse. But that they were unable provide complete documentation of the investigation. The facility was only able to provide three CNAs' witnesses statements, no other documentation of the investigation. The DON was questioned if there was any further documentation? The DON stated, No, this was all they had. Interview on 1/8/19 at 1:30 p.m. with the DON revealed when asked what type of investigation did the facility conduct following the incident with R#121 and LPN II? The DON stated, I took statements from the CNAs present, and spoke with LPN II and provided counseling for the nurse. The DON was questioned if the facility had interviewed any other staff or residents concerning care they received from LPN II and why after reading the CNA's written statement and speaking with the family did the facility not report the incident or initiate an investigation? The DON stated, No I didn't interview anyone else because after speaking with LPN II, I did not feel the incident was abuse but a customer service issue. The DON was asked for the counseling provided to LPN II but was only able to provide the nurse's orientation training from (MONTH) (YEAR). A review of the facility's staffing schedule for 12/1/18 through 1/7/19 indicated LPN II had continued to work on both nursing units that R#121 and R#55 were located. Although LPN II was no longer assigned to R#121 after the incident was reported, LPN II continued to care for R#55 after the 12/23/18 incident had occurred until the nurse was suspended on 1/7/19. Review of the facility reported incidents since the last annual survey in 2/2018 and the incident/grievance log from 8/2018 through 1/7/18 was conducted and there were no reports that included R#121 or R#121's family. 2. During an interview with CNA GG on 1/9/19 at 9:25 a.m. at the Unit 1B nursing station it was revealed that LPN II was involved in an incident with R#55. While LPN II was manually removing stool from R#55's rectum it became too painful and the resident asked to take a break. LPN II responded We don't take breaks . and proceeded with the procedure. CNA GG immediately reported the incident to the LPN EE CNA GG and LPN EE stated during interviews on 1/9/19 at 9:25 a.m. and 9:45 a.m., respectively, that they had written a statement regarding the incident as it occurred and placed it on the DON's office desk. LPN EE did not report the incident to the Unit Manager (UM), the UM was not available due to the holidays and the nurse did not recall if she had called the DON. An interview with the DON on 1/9/18 at 4:15 p.m. revealed when asked if there was any written statements from the staff concerning R#55's incident with LPN II, the DON stated, No, I wasn't aware of the situation until today. The DON was asked what should the staff do if they need to report an incident such as R#55s? The DON stated, The staff are to notify their Charge Nurse or Unit Manager. If unavailable, they are to notify either the DON or Administrator. The DON was asked what happens next? The DON stated, the facility would start an investigation to see if it was abuse or not. The staff member involved would be suspended during the investigation. A review of the facility's reportable incidents since last survey in 2/2018 and the incident/grievance log failed to indicate R#55's incident had been investigated. | 2020-09-01 |