| 50 |
GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER |
125004 |
3-3420 KUHIO HIGHWAY, SUITE 300 |
LIHUE |
HI |
96766 |
2016-10-28 |
272 |
D |
0 |
1 |
U50511 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical review (EMR) and staff interviews, the facility failed to ensure that 1 of 31 residents (Resident #90) on the Stage 2 resident sample list, received a comprehensive assessment as part of an ongoing process to identify mood and behavioral symptoms and psychosocial well-being, Also, documentation of assessment information in support of clinical decision making was not found. Findings include: On 10/26/2016 at 07:59 AM, reviewed Resident #90's physician orders [REDACTED]. The resident was prescribed antidepressants and anti-anxiety medications and was sampled for unnecessary medications for Stage 2 of the survey. On 10/26/2016 at 4:00 PM, further EMR review on Resident #90 noted on the facility's PharMerica Resident Change in Condition MRR Request Form, a request to change Resident #90's antidepressant medication due to the resident exhibiting inappropriate sexual behaviors. The form documented: Status change: Increased sexual behaviors, touching self inappropriately in public. Resident kissed another resident. Diagnosis: [REDACTED].>Current medications: [REDACTED] Possible contributing medications: [REDACTED] Name medication regimen is not thought to directly contribute to inappropriate sexual behaviors. however, __ may benefit from a change in therapy (see below). Pharmacy recommendation: Changing Name [MEDICATION NAME] ER 50 mg once daily to [MEDICATION NAME] may provide continued therapeutic benefit for treatment of [REDACTED]. Please consider decreasing [MEDICATION NAME] ER to 50 mg by mouth once every other day x 3 doses. Then start [MEDICATION NAME] 10 mg by mouth once daily x 7 days then increase to [MEDICATION NAME] 20 mg by mouth once daily thereafter. Pharmacist Signature: Name Date: (MONTH) 13, (YEAR). On 10/27/2016 at 8:20 AM, interviewed LN#3 and asked them to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 accessed the resident's Behavior Monitoring Log on the EMR which documented, Behavior #1 masturbating in Makai lobby, and on 10/02/2016 the behavior log was marked with 1, and N/A in the Interventions column. The LN #3 went to the EMR Notes tab and could not find any corresponding progress notes on 10/01/2016. Under the Care Plans tab there was a care plan (CP) ___will not show any inappropriate behavior around other residents within the next quarterly review. The interventions included: __ reports he is not aware of his behavior during staff approach. He reports he is fixing his Foley catheter; assist in covering self; assist to private area like his room; direct care staff to remove female residents when __is in the TV unit area; discuss with __in a straightforward matter of fact manner that his behavior is inappropriate. On 10/27/2016 at 8:50 AM interviewed RCM #3 to access the EMR. Asked RCM #3 to verify behavior log documentation on 10/02/16, and RCM #3 was not able to find any progress notes in the EMR to corroborate with the behavior monitoring log. The RCM #3 stated that the nurse on that date during evening shift would know what happened. Queried RCM #3 if the staff that observed Resident #90 kissing another resident made an incident report, and RCM #3 stated that there were no progress notes on the incident on 10/02/2016 but that social worker (SW) services may have the documentation. On 10/27/2016 at 9:56 AM interviewed social workers (SW), and both SWs stated that they investigated the incident of Resident #90 kissing a female resident after being informed by LN #4. According to both SWs, Resident #90 was interviewed and counseled about inappropriate behavior of kissing female resident in the TV lobby. Resident #90 claimed to have given a female resident a chaste kiss of Aloha on the cheek after receiving condolences on the recent passing of his wife. Resident #90 apologized to the SWs for kissing the female resident and stated that he is Hawaiian style and wanted to thank her with a kiss on the cheek. The SWs both stated that Resident #90 understood after being told by them that kissing of other resident is inappropriate in the facility. The SW's stated that they also spoke with the female resident and she didn't think that Resident #90 had any sexual overtures and didn't feel offended or unsafe in the facility. When asked for documentation of SW interviewing and counseling of residents on the incident and inappropriate sexual behaviors, both SW's had none to provide. Both SW's stated that they developed a care plan (CP), to address Resident #90's inappropriate behaviors. On 10/27/2016 at 10:22 AM interviewed LN #4 who had witnessed the incident of Resident #90 kissing a female resident in the TV lobby. According to LN #4, she saw Resident #90 bend down and kiss the female resident more towards her lips than the cheek area and repeatedly. LN #4 was at the nursing station within view of the TV lobby on the third floor where the female resident was sitting. Resident #90 was ambulating around the unit with the FWW and stopped to talk to the female resident. It was then that LN #4 observed Resident #90 bend down to kiss the female resident more than once. The LN #4 called out to Resident #90 to stop and another LN #5 ran over to separate them. From LN #4's observations the female resident was holding on to Resident #90 hand and didn't want to separate. Also, LN #4 had observed Resident #90 masturbating in the TV lobby, and resident would be looking around to see if anyone around. LN #4 stated that when they observed Resident #90 masturbating, they was sitting at the nursing station and stood up to ask Resident #90 if everything was ok and resident replied, I'm Ok and stopped what he was doing. LN #4 stated that they wern't the only one that observed Resident #90 masturbating in the TV lobby because other nursing staff have also reported same observations. LN #4 stated that they reported observations to RCM #3 who reported the incident to the SWs. On 10/27/2016 at 10:36 AM, interviewed the DON regarding Resident #90's inappropriate sexual behaviors with no documentation of dates, incidents, interviews, and/or IDT meetings to address the behaviors. According to the DON, Resident #90 walked into their office and DON had a spontaneous conversation with Resident #90 but cannot remember the date. Resident #90 was concerned because the DON observed the resident the evening before that conversation, sitting in the TV area with hands on his groin area. The DON stated that they had discussed with Resident #90 that others could perceive this differently and think it was inappropriate. The resident stated that they tend to sit like that and agreed it could be observed doing something inappropriate. The DON stated that they did not talk to Resident #90 about masturbating in the TV lobby. The DON verified that there was no documentation on Resident #90's inappropriate sexual behaviors as discussed by the SWs, nursing staff and themselves. On 10/27/2016 at 10:50 AM, interviewed RCM #3 and he stated that their role is that of a nursing supervisor. The RCM #3 stated that after nurses reported inappropriate sexual behaviors displayed by Resident #90, the incidents were reported to the team (DON & SWs). The issues were discussed but RCM #3 stated that they would have to go through Resident #90's EMR to find any documentation. On 10/28/16 reviewed the EMR for Resident #90 and noted that RCM #3 and SW made late entries on 10/27/2016 in progress notes to document the above incidents: Social service wrote: On 9-8-16 writer spoke with Resident #90 in SS office, RCM informed SS that Resident #90 was observed touching his private area out in Mauka 3 lobby area. Writer followed up with Resident #90 and he confirmed he is not touching self and is fixing his Foley tube. Resident #90 verbalize to writer that he keeps his hands close to his private area all his life as he is most comfortable, Writer informed Resident#90 .He is not a risk to others. He doesn't go into other resident's rooms, no displays of aggressive behaviors or sexual behaviors towards others. Nursing Late Entry: Writer asked Resident #90 about any issues with the catheter, if has any itch on the area or any discomfort; because per nurses he is seen putting his hand near his genitals; resident verbalized that he does not have any discomfort in area; writer discussed this incident with the IDT; as for further intervention for past sexual behaviors, writer made a medication review consult thru pharmacist; added a behavior log for further monitoring of past sexual behaviors; Resident #90 is not a threat to any resident in the facility and has not displayed any sexually aggression to anyone; or noted to be sexually inappropriate to anyone, The EMR review also included these CPs: CP: ___had been noted with hands close to his genitals. ___confirmed he is not touching self inappropriately and is fixing his Foley tube. ___verbalize to SS that he keeps his hands close to his private area all his life as he is most comfortable. Goals: ____will not be observed having close hand contact to genitals with in the next quarter Int: ___reports he is not aware of his behaviors during staff approach. He reports he is fixing his Foley catheter, assist __in covering self, assist to private area like his room Direct care staff to remove female residents when ___is in the TV unit area Discuss with ___in a straightforward matter of fact manner that his behavior is unacceptable ___Reports he has a habit of placing his hands in his upper thigh area close to his private part ___has regular visits with neurology doctor. MD response made d/t behaviors and MD stated d/t SE of his [MEDICAL CONDITION] medication Remind ___of need to respect other resident's rights OBSERVE ___at times-keep other female resident distance from him CP: __is on [MEDICATION NAME] for REM disorder/[MEDICAL CONDITION] __has [MEDICATION NAME] DX: Situational depression. [MEDICATION NAME] d/c'd on 09/16/16 and started on [MEDICATION NAME] on 9/25/16 for situational depression. |
2020-09-01 |