| 7396 |
A.G. RHODES HOME WESLEY WOODS |
115002 |
1819 CLIFTON ROAD, N.E. |
ATLANTA |
GA |
30329 |
2017-01-25 |
223 |
G |
1 |
0 |
HX8G11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy and procedure and interview, the facility failed to ensure that one of three sampled residents (R) (R#1) was free from abuse. Specifically, actual harm was identified on 12/26/16 when R#1, a resident with advanced dementia and [MEDICAL CONDITION], was mistreated in the form of physical abuse, mental abuse, intimidation and corporal punishment when a Certified Nursing Assistant (CNA) FF pulled the resident backward in his wheelchair from the back of his collar and back of his shirt. R#1 would not respond to interview questions however, a telephone interview with the Family on 1/25/17 at 3:55 p.m. revealed she recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed a review of the facility video surveillance confirmed the abuse and she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. This incident was entity reported to the State Agency on 1/12/17 (GA 510). Findings include: Review of the facility's undated policy titled Abuse Prevention Policy and Procedures documented: It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, exploitation or misappropriation of resident property. We believe each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. This policy applies to anyone subjecting a resident to abuse including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment is the inappropriate treatment or exploitation of a resident. Review of the facility's follow up letter to the State Agency- Long Term Care Section- Compliant Unit dated 1/18/17 documented: During the course of a facility investigation conducted on 1/12/17 (into an unrelated, unsubstantiated complaint involving Certified Nursing Assistant (CNA) FF reported on 1/10/17), CNA AA reported there had been an inappropriate incident that she witnessed on 12/26/16 involving CNA FF and R#1. CNA AA reported that on 12/26/16, around dinner time, she observed that R#1 was very restless and agitated that evening and kept trying to get out of his wheelchair and staff were redirecting him because they were afraid he would stand up and fall. Toward the end of the meal, CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. The motion caused him to fall back into the chair and then she pulled him backwards in his wheelchair by the collar/back of his shirt toward the direction of his room. The Director of Nursing (DON) was able to review camera footage of the incident which occurred in the 2S dayroom area and was time stamped on 12/26/16 at 5:40 p.m. Details of incident indicated R#1 is seen seated in his wheelchair with CNA GG seated behind him. He appears restless and persists in trying to stand from the chair. CNA GG is seen redirecting him by patting his shoulders in a reassuring manner. CNA FF is then seen clearing the table of dishes, placing them in a tray rack, then turns and walks toward R#1 who is seated in his wheelchair. CNA GG walks away down the hall, then CNA FF is seen grabbing and pulling R#1 by the back of his shirt collar and begins to roll him backwards in his wheelchair by pulling on his shirt. She then changes her hand position to grab the middle of his shirt and continues pulling him backward to his room. The facility does substantiate CNA wrongdoing and suspicion of resident mistreatment in this incident. CNA FF was terminated on 1/13/17 related to this incident with R#1 for suspected mistreatment of [REDACTED]. The facility immediately followed up this incident by conducting all-staff-in-services on abuse policy and procedure and reporting protocols. R#1 was assessed for any physical injury, none noted. The Family of R#1 was notified of this incident and facility follow-up to protect residents from future occurrences. The Family stated that she recalled one evening recently that a nurse called to report that she was having problems giving R#1's medication and reported that he seemed more agitated than usual. The Family stated she talked to her husband on this occasion and he told her someone is pushing me around and being mean to me. The Family could not remember the nurse's name or the date of this conversation with the nurse and her husband but believes it may correspond with the timing of the incident. Record review for R#1 indicates this is a [AGE] year old male, admitted to the facility dementia unit on 10/26/16 with primary [DIAGNOSES REDACTED]. The resident has a history of falls with left [MEDICAL CONDITION] July 2016. He is alert with confusion, has limited speech and impulsive behaviors with no safety awareness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 99, indicating the resident was unable to complete the interview. The resident's cognitive skills for daily decision making is moderately impaired. The resident has disorganized thinking that fluctuates, comes and goes and changes in severity. The resident did not exhibit behaviors. The resident required extensive assistance with all Activities of Daily Living (ADL) except with eating. An interview on 1/25/17 at 2:21 p.m. with CNA AA revealed the day of the incident, was the day after Christmas and it was me, CNA FF and another employee (CNA GG) in the dining area with R#1. The other employee (CNA GG) no longer works here so I'm the only witness. That day R#1 was real agitated because he hadn't seen his wife and he wanted to go see his wife that day. R#1 was walked from the north side dining room to the south side dining which is next to his room. He was agitated and CNA FF had him (sic) and it was time for his shower. CNA FF went to put the resident in the wheelchair and he got back up. CNA FF pulled R#1 by his shirt back into the chair. He wasn't injured but he was already upset and this aggravated him more. R#1 is a sweet guy. He only really wants to get in his bed. He doesn't want to get up until it's time to go to the dining room, then he wants to go back to the bed and to watch CNN. An interview with R#1 was attempted on 1/25/17 at 3:13 p.m. R#1 did not respond to any questions or engage in conversation. A telephone interview on 01/25/2017 at 3:55 p.m. with the Family of R#1 revealed that on the evening of the incident, R#1 called to tell her that a girl had pushed him around. The Family told R#1 they love you and wouldn't hurt you and they are going to put you to bed. She added, the facility called her at a later date that she could not exactly remember, and told her that the girl (CNA FF) grabbed him and jerked him around by the shirt. The Family of R#1 recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview, during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed that during an investigation for a different situation that involved CNA FF (that was not substantiated), CNA AA told her about the incident that occurred on 12/26/16 in the dining room. She said the CNA AA told her that CNA FF snatched the back of the resident's shirt causing him to fall back into his wheelchair. The DON reviewed the facility surveillance video and stated that she could see R#1 seated in his wheelchair but could not see from that view if CNA FF pulled him into his wheelchair. The DON Stated that she could see on the video that CNA FF grabbed the back of the resident's shirt collar and began pulling him backward in his wheelchair. She said she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. CNA FF then switched her hand position and grabbed the middle back of the resident's shirt and continued to pull him backward in his wheelchair towards the direction of resident's room. The DON stated that she called the Resident's Family member to notify her of the incident. The DON stated that the Family member remembered receiving a call from the nurse telling her he was much more agitated than usual and that R#1 wanted to talk to her. The Family stated that when she spoke to the resident on the phone that evening and he told her someone was pushing him around and being mean to him, at first she thought he was probably confused so she did not report it to the facility. The Family felt bad that she did not believe him. Review of a written statement signed by CNA FF and dated 1/13/17 documented: After dinner the resident (R#1) was very upset because he wanted to talk to his wife at the time I didn't know that he can walk so I grab him by the pants to sit him down so he won't fall and I pull him hack. So to his room so we can come him down and we took him to the shower and I played like I was his wife and he come down. Yes he was come and went to sleep. So I left out and went back and started to feed in the dinner. (sic) Review of a written statement signed by CNA GG and dated 1/18/17 documented: I did not see CNA FF grab R#1 by his shirt. I hand him over to her and walked away to get his stuff together for the shower. So once my back was turn I didn't see anything happen after that. This incident happen 12/26/16. (sic) Review of an undated written statement signed by CNA AA documented: R#1 was very restless and agitated and he kept trying to get up out of his wheelchair. The staff was trying to redirect him because they were afraid he would stand up and fall. Toward the end of the dinner meal at around 5:30 p.m., I observed the following: CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. This caused him to fall back into his wheelchair and then she pulled him backwards in his wheelchair toward the direction of his room. Review of a facility Employee Conference form dated 1/13/17 revealed CNA FF was given a final warning. Action taken was termination based upon mistreatment of [REDACTED].#1 on 12/26/16 at 5:40 p.m.-incident reported to the State office). Review of a facility employee conference form dated 1/18/17 revealed CNA AA was given a warning for poor work performance: Failure to report suspicion of resident mistreatment timely. Action taken: Immediate improvement needed or further disciplinary action will result up to and including termination. Goal: Understanding and follow-through to timely reporting of any pertinent observations related to resident treatment and care. Approach: Monthly in-services on abuse policies and procedures for three months. Review of documents titled In-Service Training Report revealed the following: On 11/21/16 the Topic of in-service was Abuse P&P (Policy and Procedure) which included a sign in sheet on the back of the document with a signature of attendance by CNA FF. On 12/28/16 the Topic of the in-service was Abuse P&P- How to report abuse which included a sign in sheet on the back of the document with signatures of attendance by CNA FF and CNA AA. On 1/11/17 the Topic of the in-service was Abuse P&P, employees present: CNA's, Nurses. Included sign-in sheet revealed 61 employee signatures in attendance. CNA AA's signature was included on this sig-in sheet. On 1/18/17 the Topic of the in-service was Abuse P&P- Reporting Guidelines which included a sign in sheet with one signature of attendance, CNA AA. Review of the Georgia Criminal History Name and Identifier Search dated 5/25/16 for CNA FF indicated no criminal records found. |
2017-04-01 |