| 30 |
BINGHAM MEMORIAL SKILLED NURSING & REHABILITATION |
135007 |
98 POPLAR STREET |
BLACKFOOT |
ID |
83221 |
2016-06-17 |
225 |
D |
0 |
1 |
J25411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident, staff and family interview, it was determined the facility failed to ensure that for 1 of 2 investigations reviewed for abuse/neglect, the allegations were identified as potential neglect and investigated and processed as such. This was true for 1 of 2 residents (#7) whose allegations and investigations were reviewed. The facility failed to recognize an allegation as potential neglect and handled the investigation as a general care complaint. This compromised the ability of the facility to identify, thoroughly investigate, and initiate corrective actions necessary to protect residents from neglect. Findings include: Resident #7 was admitted to the facility on [DATE] for rehabilitation following a total knee replacement. She had an admission [DIAGNOSES REDACTED]. At the time of admission, Resident #7 required staff assistance for toileting and transfers. During an interview on [DATE] at 2:10 pm, Resident #7 stated that she had problems with her bladder when she was initially admitted after knee surgery. She stated it was hard for her to get to the bathroom on time. Resident #7 stated that initially, it took 2 to 3 staff to assist her with toileting because of her limited weight bearing status following surgery. She stated she was prescribed [MEDICATION NAME] and was incontinent the first couple days because staff did not help her. Resident #7 stated she waited an hour to an hour and a half to be toileted. Resident #7 reported staff came to her room and turned off her call light and said they would come back, but did not come back. She stated she remained in wet incontinence briefs for extended timeframes. Resident #7 stated staff got angry when they had to come and assist her to the toilet. It took several staff to do so and reported one staff member stated, Again? when she needed assistance to toilet. Resident #7 suggested the surveyor speak with her family member, Family Member #1, because this family member reported these concerns to administration and could provide the details. Family Member #1 was interviewed on [DATE] at 3:00 pm. Family Member #1 stated Resident #7 was admitted to the facility for rehab about a week and a half ago. Family Member #1 stated Family Member #2 was with Resident #7 during the day she was admitted ([DATE]) to the facility following surgery. Family Member #1 stated he was with Resident #7 during the second day ([DATE]) following Resident #7's admission and that both he and Family Member #2 went and spoke with the Administrator due to their concerns. Family Member #1 stated Resident #7 had been completely continent prior to the surgery and was aware when she needed to use the toilet. Family Member #1 stated Resident #7 had a catheter in the hospital but it was removed prior to her coming to the facility. He stated Resident #7 was put into incontinent briefs when she was admitted to the facility even though she was continent. Family Member #1 stated both he and Family Member #2 observed Resident #7 waiting too long for assistance and Resident #7 was incontinent, urinating in her brief, as a result. He stated he had medical training and helped Resident #7 to the toilet twice when he was visiting because staff did not come timely and Resident #7 had already been incontinent. Family Member #1 stated he was concerned because Resident #7 had what looked like skin breakdown to her bottom. Family Member #1 stated he and Family Member #2 spoke with the Administrator on Monday [DATE]. Concerns raised included Resident #7 being put in incontinence briefs, the long wait for toileting assistance, call light response time, and Resident #7 remaining in wet briefs for an extended time. Family Member #1 also reported an interaction with a nurse who forcefully stated, Bullshit when he reported a concern about whether Resident #7's skin had been assessed upon admission. Family Member #1 stated he was concerned when he observed Resident #7's skin as it looked like she had skin breakdown to her buttocks area. Family Member #1 stated the Administrator was concerned when the issues were reported on [DATE] and told both he and Family Member #2 that it would be handled as a state level complaint. Family Member #1 stated the Administrator had not followed up with him regarding the outcome of the investigation. A BMH Concern Form, dated on [DATE] at 1:30 pm, documented the concerns raised by Family Member #1 and Family Member #2. A Bowel and Bladder Continence Evaluation, dated [DATE], documented Resident #7 was incontinent of urine a total of 4 times on [DATE] and on [DATE]. On [DATE] and [DATE], there were no recorded incidents of incontinence; however, there was one incident of Resident #7 being wet. The SNRC Admission Assessment, dated [DATE], stated Resident #7's buttocks area were red and excoriated. Review of the Bingham Memorial Skilled Nursing and Rehabilitation Center and Bingham Memorial Hospital Abuse and Assault (Child Abuse/Neglect; Elder Abuse/Neglect; Domestic Battery, Sexual Assault) policy, created [DATE] and expired on [DATE], defined neglect as, The failure of a caretaker to provide food, clothing, shelter, or medical care necessary to sustain the life and health of a vulnerable adult . Examples of physical neglect were documented as, Inadequate provision of care .Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The abuse/neglect policy stated if an allegation of neglect was made for a resident in the facility that did not reach the level of serious, life threatening injury or death, staff must notify the Administrator and DNS. The Administrator was responsible to contact the SNRC Social Worker to proceed with reporting requirements of within 24 hours to the State Agency, Bureau of Facility Standards. The SNRC Social Worker or designee would then fax a written report to the Bureau of Facility Standards within 5 days. The Administrator was interviewed on [DATE] at 2:00 pm. He stated Family Member #1 and Family Member #2 came into his office on [DATE] and expressed their concerns regarding Resident #7's the lack of care. He stated he grabbed a complaint form and documented their concerns at that time. He stated he went to the charge nurse after the discussion and began investigating the concerns immediately. He stated that he found out Resident #7 was admitted with an incontinence brief on and that a skin assessment was completed upon admission. He stated he directed staff to respond timely to call lights and toileting assistance. He verified (nurse's name) said, Bullshit when Family Member #1 questioned whether an initial skin assessment was completed. The investigation did not include documentation of interviews with nursing staff members who worked with Resident #7 on [DATE] and [DATE] or any other method to determine whether adequate toileting assistance was provided. The investigation did not include interviews with other residents to determine whether their needs were met on those dates. The investigation did not include an interview with Resident #7 at that time; she was interviewed during the survey. When asked about reporting the incident as an allegation of potential neglect to the State Agency, the Administrator stated the incident should have been reported to the social worker. He stated he had not considered the allegation as potential neglect at the time, but could see how a failure to provide care and services (toileting) met the criteria. He verified the incident was not reported to the State Agency within 24 hours and a report was not faxed to the State Agency within 5 days. |
2020-09-01 |