cms_MT: 994
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 994 | CLARK FORK VALLEY NURSING HOME | 275107 | 10 KRUGER RD | PLAINS | MT | 59859 | 2016-11-03 | 225 | E | 0 | 1 | WOF111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report allegations of verbal abuse involving several staff members, and show evidence of a thorough investigation for the events. This failure had the potential to affect all resident's involved in the allegations; and the facility failed to report and show a thorough investigation for a bruise of unknown origin for 1 (#5); and failed to report and show a thorough investigation for a bruise and a skin tear of unknown origin, for 1 (#9). This failure had the potential to affect all residents who had injuries of unknown origin. The facility also failed to show in all of the above events, how the facility identified and implemented interventions for the prevention of abuse or unknown injuries in the future for those resident's affected. Findings include: 1. During an interview on 11/3/16 at 7:25 a.m., staff member A stated there were alleged observations of three staff members verbally abusing residents in the recent past. Staff member A stated she reported the events up the chain of command, but did not provide information on the resident's affected, or time frames for the events. Review of a written document, dated 10/5/16 at 9:30 a.m., showed staff member A had interviewed four staff members, identifying one as having multiple, verbally aggressive behavior towards residents. Staff member A stated she spoke to the staff members in question. Staff member A stated she was not aware of the need to report allegations of abuse if there had been an investigation completed by the facility, and staff were reprimanded or trained. Review of the facility policy, with a revision date of 7/31/07, and titled Long Term Care, Abuse, Neglect and Exploitation of Elderly and Disabled, showed the facility was to report immediately an alleged abuse incident to the State Agency. Review of the Abuse Reporting/Investigation policy, with a revision date of 7/07, showed the facility was to complete an investigation within five days and send a report to the State Agency. Review of the facility's reports to the State Agency (SA) did not show the allegations, dated 10/5/16, had been reported to the S[NAME] 2. Resident #5 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS, with an ARD of 10/7/16, showed the resident generally communicated her needs except during episodes of confusion. Resident #5 required maximum assist with bathing from one care giver. A review of facility skin documentation showed skin checks were usually completed on bath days. Review of the nursing progress notes, dated 7/30/16, showed a black bruise, measuring 2 centimeters by 1 centimeter, it was found on resident #5's left forearm. The nursing staff entries following this entry, lacked additional investigative information about the black bruise, which was an injury of unknown origin. 3. Resident #9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Annual MDS, with an ARD of 5/6/16 and the Care Area Assessments dated 5/12/16, showed resident #9 usually understood the speaker, and answered questions appropriately except during episodes of confusion. Additionally, resident #9 was totally dependent on one care giver for bathing. Review of facility skin documentation showed skin checks were completed on days residents received a bath. a) Review of the nursing progress notes, dated 4/30/16, showed a blue bruise measuring 2 centimeter by 1.5 centimeters was found on resident #9's left buttock near her coccyx. The center of the bruise had a superficial opening that measured 1 centimeter in diameter. The nursing staff entries following this entry lacked additional investigative information about this injury of unknown origin. b) Review of the nursing progress notes, dated 11/1/16, showed a skin tear, measuring 2 centimeters in length, was found on resident #9's right forearm. There was bruising around the skin tear. [MEDICATION NAME] was applied to the injured area. The nursing staff entries following this entry, lacked additional investigative information about this injury of unknown origin. During an interview on 11/3/16 at 10:30 a.m., staff member A stated these injuries were not reported to her for investigation and reporting to the S[NAME] She said she started the investigations and the reporting process for the injuries of residents #5 and #9. She stated the staff were to report all injuries of unknown origin to her for an investigation to be completed. Review of the facility's Administrative policy, titled Long Term Care Neglect and Exploitation of Elderly and Disabled, showed all injuries of unknown origin, and alleged violations of abuse shall be reported to the administration of the facility and other officials in accordance with the State law (including the State Survey and Certification). The policy also showed all alleged violations would be investigated thoroughly. The SA did not receive reports or investigations from the facility for any of the aforementioned injuries for residents #5 and #9, prior to the survey date of 11/3/16. The facility failed to provide evidence that the injuries and events were thoroughly investigated, including any follow up action or potential interventions to prevent injuries in the future. | 2020-09-01 |