| 5 |
HILO MEDICAL CENTER |
125002 |
1190 WAIANUENUE AVENUE |
HILO |
HI |
96720 |
2018-11-16 |
600 |
G |
0 |
1 |
HKBQ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review facility failed to protect resident's right to be free from any type of abuse that results in, or had the likelihood to result in physical harm, verbal abuse, or mental anguish in four Resident's (R) 10, R20, R22, and R30 in the sample of 16. The facility failed to provide care planning interventions and supervision to prevent three incidents involving R30. An incident on 08/09/2018 resulted in R22 striking R30 after verbal confrontation with R30. On 11/04/2018, R30 and R20 had an abusive verbal confrontation that required staff to render a show of force to prevent a physical confrontation. On 11/12/2018, R10 was involved in a verbal confrontation with R30, when he felt R30 was loud and rude to staff. This deficient practice caused harm for R30 resulted in high potential to endanger the other 24 residents residing in the extended care facilitl section. Findings Include: During initial screening of residents on 11/13/2018, R25 expressed she would like to discuss concerns about R30. During a brief interview on 11/14/2018 at 10:50 AM, R25 stated, R30 upset the blind man (R22) to the point he went after him. He is verbally obnoxious. I give the staff credit as they are kind to him. During an interview with resident council members (R10, R22, R25, and R29) on 11/14/2018 at 10:45 AM R22 stated. There's a guy (R30) here who I got into it with. He talks all the time and goes on and on. A couple of months ago I was in the same room and got sick of it and punched him. R10 stated, He is bad to the staff how he talks to them and obnoxious. R29 stated, He was kicked out of bingo and has to know everything about everyone's business. R10 said, He has no respect for women. R25 stated, He (R30) asks one of the CNA's if she'll marry him. She told him she was married, and he tells her to divorce and marry me. When asked if the resident's present felt safe, they replied yes. R10 stated, He's not safe in our environment. When asked to explain, R22 said, Concerned someone will get upset with him because he's so obnoxious, always swearing and in everyone's business. Shared that R30 had been observed to be sitting alone in the dining room this morning. R10 responded. Staff have asked him to stay away, but he gets up and goes to the tables anyway and starts talking. During an interview with Director of Nursing (DON) and Administrator on 11/15/2018, about R30's behavior, AHA described him as Portuguese and very talkative. He is not offensive to everyone. Asked what interventions have been put in place to prevent further altercations involving R30, and AHA stated, We are working with them one to one to help them understand R30's communication style and separate them in the dining area. The residents committed to notify the staff if they feel frustrated with R30's conversation prior to addressing it directly with him. There has not been a second incident with these resident's (R10, R20 and R22). The concern regarding R30's safety discussed at Resident's Council interview was discussed. AHA stated, No one will be able to remain here if threats are made. Clarification made, and it was reiterated that the statements made were not made as a threat but interpreted as [MEDICATION NAME] concern that due to the ongoing verbal persistence of R30, any resident might unexpectedly react and harm R30. The level of frustration verbalized at Resident's Council interview revealed the interventions to date were not adequate and concern expressed for further occurrences. During a brief interview with AHA on 11/16/2018 , additional records were requested for care plans after the three incidents. AHA was asked if there was anything that could have alerted them or factors that could have been foreseen to prevent the incident on 08/09/2018 when R30 was struck. AHA replied, No, there was nothing. EMR reviewed R30 was known and identified on the baseline care plan as having difficult behavior, demanding and verbally abusive communication. On 08/09/2018 RN55 was made aware by R22 that he was upset with R30 and needed to talk. R30 and R22 were left in the room unsupervised resulting in a physical altercation. Interventions put in place after the incident were not effective in reducing behaviors resulting in a second and third incident involving R30. A behavioral contract was not developed with R30 until after the third incident on 11/19/18. On 08/09/2018 at 05:20 PM, an altercation occurred between R30 and R22. The incident report completed by RN55 documentation includes the following: R22 stating earlier that he wanted to talk to R30 about squealing to MSW (Master of Social Work). R22 states MSW talked to him and R10 during the day about complaints of them being mean to R30. Upset R30 went behind his back to talk to MSW instead of saying it to his face, stated he wanted this writer to be there as witness because R30 was lying to MSW. Notified R22 that he can talk to resident but not argue or do anything physical, to call this writer when he was ready to talk. R30 was sleeping when this writer left room at 1700. Notified by Certified Nursing Assistant (CNA)16 at 17:20 that .R22 who was hitting . R30 during dinner. R22 said he brought up the issue of R30 squealing on him then R30 said used profanity. R22 states he lost it got up and started swinging his arms trying to hit R30 who was in bed. R22 is blind and states he just went toward R30's voice. RN55 told R22 he, should have called this writer like he promised. CNA16 states R22 was hitting the left side of R30's body, she pulled R22 away. R30 was moved to another room after the incident. Review of R30's Social Services notes by Social Worker (SW)1 include: On 08/10/2018 at 07:30 AM. R30 again stated he had no physical pain but said he was emotionally hurt. The SW responded the staff would keep him safe. On 08/10/2018 at 02:35 PM. At approximately 12:30 PM the resident said he did not feel safe, and felt restless and not normal. further describing the event as a trauma. The SW said to the degree he could, R30 should try to maintain a normal routine and be involved in activities within the group. R30 said, What if he comes in my room after me? The SW reassured R30 that R22 was not prone to this and, with the two men being in separate spaces, it was not at all likely to happen. On 08/10/2018 at 02:53 PM. R30 stated he felt safe but expressed anger at his former roommate who had hit him. On 08/13/2018 at 02:00 PM. R30 spoke several times with the SW throughout the day. He complained that his former roommates were being mean to him. He described looks and them whispering. The SW said he would attempt to address it with the other men but said the (sic) he needed to give that situation time since there had been overt conflict that previous week. Review of SW1 follow up notes for R22 include: On 08/10/2018 at 07:45 AM. R22 said he was upset the SW had spoken to him about R30's concerns with him (R22). Other residents reported that R22 shouted for R30 to shut up loudly in the dayroom on 8/8/18. R22 said I no care you kick me out of here. The resident (R22) said, I tell him you come to me if you got a problem with me. He said, Don't hide behind other people Brah. The SW also pointed out that three roommates had come and gone with R22 and the third roommate R10. The SW said that such physical attacks could not happen, as all residents needed to feel safe. On 08/24/2018 Subjective findings in R30's progress notes by Advanced Practice Registered Nurse (APRN) reviewed: We discussed the interpersonal challenges he has been having with peers and staff. He has been in 7 care homes. APRN's assessment included Borderline personality disorder-continues to have interpersonal problems, however willing to practice communication strategies with staff and distancing strategies with unfriendly peers. On 11/04/2018 an Office of Healthcare Assurance ([NAME]HA) report revealed a second incident involving R30. The event was described as follows: R20 was heard swearing at R30. Staff heard R20 state in a very loud voice, what! What!; As R20 was swearing, he was approaching R30. (Both men utilize front wheeled walkers for mobility assistance.) R30 was seated with other residents; facing the front of the .building, R30 was reacting to R20 and also began to curse at him. Staff approached both men and asked them to stop their behaviors. R20 appeared to be preparing to strike out at R30, as he was bringing his right hand backwards. However, staff was able to place themselves in a position to gain R20's attention and state, Stop. You need to go back to your room and calm down. R30 continued his taunt. R20 began to become more upset. He was becoming more difficult to redirect. Along with the staff aide, the activity aide, as well as the housekeeper was able to render a show of force, which successfully dc-escalated (sic) the situation. R20 returned to his room. R30 was advised not to approach or antagonize R20. The report documents, There were no issues prior to this event; as these residents had not associated with each other prior to this encounter. Causal factors identified by the facility were documented as: R30, had settled in to the facility; he continues to have a tendency to repeat self; making persistent verbal requests of others. R20, does have instances of verbal outburst that lends to his self-isolation. There were noted precipitating factors that could explain the incident. On 11/06/2018 an email From CNA26 was sent to the Director of Nursing (DON) which said R20 was only inches away from R30's back and ready to swing his hand on his back. R20 were about to turn around when R30 started to talk and teased him to fight. R20 got more upset and unable to redirect.' R20 had no plan to stop attacking R30. On 11/12/2018 a verbal altercation occurred between R30 and R10. The [NAME]HA initial report describes: R10 was trying to stop R30 from speaking loudly and rudely to the Recreational Aide. Survey team was on site 11/13/2018. RN56 nurses notes dated O7/24/2018 stated Resident's daily routine People say I talk too much and identified potential barriers to his discharge/ goals as: Hx difficult behavior, and demanding + verbally abusive. Comprehensive care plan dated 07/25/18 reviewed, no evidence of interventions to address identified difficult behavior and demanding, verbally abusive behavior noted. On 08/10/2018 at 10:34 AM, R30's comprehensive care plan revised after the incident on 08/09/2018, to include the following interventions: Please remind me if my verbal persistence is upsetting others. Let me know what good behaviors look like. Approach me in a gentle sensitive manner. Talk calmly. On 08/14/2018 Additional interventions include: Please ask me if I am upset. Offer me reassurances, but also encourage me to distract myself in places I feel safe, such as my new room or in common areas with staff. Allow me to vent over my feelings of frustration or anxiety, but direct me if I repeat themes after reassuring me this will not re-occur. My feelings get hurt if no one talks to me. On 09/17/2018 Please encourage me to resume my daily routine (out for activities, engaging others in conversation, out for meals etc. Remind me that others may not respond the way I expect them to. On 11/04/2018 After second incident, care plan revised to include: Changed to every 15 minute monitoring due to altercation. On 11/12/2018 after the third incident, care plan revised, I will be monitored so that another resident(s) I had a verbal altercation with will not be in the dayroom at thie(sic)same time as I am until further notice. On 11/16/2018 care plan revision, I will have 1:1 visit with my SW/LTC Administrator to verbalize my feelings and any concerns that I have. On 11/17/2018 care plan revision I am receiving 1:1 supervision due to verbal altercation I had with another resident (R10). 11 dc' d (discontinued) 11/20/2018. On 11/19/2018 NHA (Nursing Home Administrator) informed of behavioral contract developed and R30's agreement and signature provided. |
2020-09-01 |