| 5186 |
EL DORADO MANOR NURSING HOME |
285253 |
71434 HWY 25, BOX 97 |
TRENTON |
NE |
69044 |
2016-11-08 |
223 |
H |
0 |
1 |
8A4D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number: 175 NAC 12-006.05 (9) Based on observation, record reviews and interviews, the facility failed to protect residents from abuse by failing to: 1) suspend employees after receiving reports of alleged verbal, psychological, and physical abuse; and 2) immediately initiate an investigation of these allegations. This affected 3 of 6 sampled residents (Residents 15, 16, and 18). The facility identified a census of 37 at the time of survey. Findings are: [NAME] Review of Resident 15's annual MDS (Minimum Data Set-a comprehensive resident assessment tool used to develop a resident's care plan) dated 12/24/2015 revealed an admission date of [DATE] and a BIMS (Brief Interview for Mental Status) score of 14 which indicated Resident 15 was cognitively intact. Interview with Resident 15 on 11/01/2016 at 11:40 AM revealed that the facility Administrator had verbally intimidated Resident 15 and Resident 16 by stating if you don't like it you can leave after they brought up concerns they felt the facility needed to address. Resident 15 also revealed that the Administrator accused Resident 15 of violating HIPAA laws because they got permission from Resident 16 to bring up an issue about Resident 16 not being able to get a haircut. Resident 15 revealed that the Administrator told Resident 16 that they should not be paying for a ride to go to their house when they did not have money to pay for other things. Resident 15 stated feeling psychologically abused and bullied by the Administrator. Interview with Resident 15 on 11/01/2016 at 11:59 AM revealed that, when Resident 15 inquired about a facility staffing change, the administrator said in an antagonistic way it's all taken care of. Resident 15 had reported to the facility staff feeling psychologically abused and bullied by the facility Administrator. Interview with the DON (Director of Nursing) on 11/02/2016 at 9:55 AM revealed the facility Administrator was brash and short with people. The DON further revealed that the governing entity for the facility had been notified about the concerns with the facility Administrator; the DON confirmed that the facility Administrator continued to work in the facility. Observation of the facility during the survey period of 10/31/2016 to 11/8/2016 revealed the facility Administrator was working in the facility. B. Review of Resident 16's annual MDS dated [DATE] revealed an admission date of [DATE] and a BIMS score of 15 which indicated that Resident 16 was cognitively intact. Interview with Resident 16 on 11/01/2016 at 10:58 AM revealed that the facility administrator had threatened to make Resident 16 move out of the facility on 3 separate occasions. Interview with Resident 16 on 11/02/2016 at 2:06 PM revealed that the facility Administrator had called them bad and had taken away their tools. Resident 16 also reported that the facility staff member had said Resident 16 was evil and that the facility had called the cops because Resident 16 had made a joke that was taken out of context. Resident 16 expressed that the facility Administrator just did not know when to stop and constantly told Resident 16 about stuff Resident 16 did wrong. Resident 16 reported that the facility Administrator told them if you don't like it here you can leave when Resident 16 brought up concerns and Resident 16 had heard the facility administrator threatening other facility staff. They threaten everybody. Resident 16 reported that living at the facility felt like prison and they felt like they could not come and go as they pleased. Resident 16 also reported that the facility staff did not make arrangements to take the residents on outings and prevented Resident 16 from making an attempt to retrieve some personal belongings from a residence that Resident 16 had previously owned. Resident 16 reported that they had saved money to pay for public transportation to take them to a prior residence to retrieve some personal belongings, but the administrator refused to let them leave the building and told them they weren't going to bring anything else into this building. Interview with the DON on 11/02/2016 at 9:55 AM confirmed that Resident 16 had made their own arrangements to retrieve some belongings of theirs that may have been at a residence previously owned by Resident 16 and that the administrator intervened. The DON revealed they did not know if the Administrator had made any effort to assist Resident 16 with retrieving their belongings. Interview with the administrator on 11/03/2016 at 4:26 PM revealed that Resident 16 had made arrangements to go to their previously owned home and retrieve some belongings. The administrator confirmed that they told Resident 16 they should not be going. The administrator revealed they did not contact the current owners of the residence to make arrangements for Resident 16 to retrieve their belongings. The administrator revealed they did not document the issue and was aware that Resident 16 was upset about not being able to go to the house and retrieve the belongings. C. Interview with NA-H (Nurse Aide) on 11/03/2016 at 1:15 PM revealed that NA-H had worked with NA-J who had been rude, mean, and rough with the residents. NA-H revealed that the facility administrator knew about it for a while and did not do anything about it. Interview with NA-H on 11/03/2016 at 1:59 PM revealed that they had reported NA-J being rude, mean, and rough with the residents 3 weeks ago to RN-C (Registered Nurse). NA-H reported that RN-C had them write out a statement and put it under the administrator's door at that time. NA-H revealed that NA-J continued to work in the facility after that and NA-J provided directed resident care. NA-H revealed that a couple of residents refused to allow NA-J to care for them. NA-H revealed that a couple other residents also had issues with NA-J after that and that NA-J continued to work. NA-H revealed that last Tuesday (10/25/2016) a couple of residents said they didn't want NA-J to take care of them and felt that NA-J was hurting them. NA-H revealed they had reported the concerns regarding NA-J again to RN-C on 10/25/2016. NA-H revealed that the DON found out about it on Wednesday (10/26/2016) and NA-J was finally fired. Interview RN-C on 11/03/2016 at 2:07 PM confirmed that they had received reports from staff and residents that NA-J was rough with the residents. RN-C revealed that they had left a note for the DON and had called the DON. RN-C revealed they had not reported the allegations to the facility administrator. Interview with LPN (Licensed Practical Nurse)-L on 11/03/2016 at 2:16 PM revealed that it had been brought to their attention several times that NA-J was abrasive with and rude to the residents. LPN-L confirmed that Resident 18's family member had reported to them that NA-J had been rough with Resident 18 and that NA-J had continued to work. LPN-L reported that they had left a note on the DON's door regarding the concerns about NA- [NAME] LPN-L revealed that RN-C had left a note on the DON's door about the concerns with NA-J when it was first reported to them. LPN-L revealed being unaware if the DON was contacted by phone or if the administrator had been notified. Interview with Resident 18's family member on 11/07/2016 at 12:29 PM revealed that Resident 18 had reported to them about 2-3 weeks ago that NA-J had been rough with Resident 18. Resident 18's family member revealed that NA-J had left bruises and a fingernail mark on Resident 18's hands. Resident 18's family member revealed that they had reported this to the nurse aides and they told them to report it to LPN-L. Resident 18's family member revealed that staff said they had left a note under the door for the nurse for Monday. Resident 18's family revealed they were never contacted by the facility regarding the incident. Interview with the DON on 11/03/2016 at 3:01 PM revealed that NA-M reported to them on (MONTH) 26th, that Resident 18's family had reported that NA-J was rough with Resident 18. The DON revealed having no prior knowledge of the allegations regarding NA-J as the DON was on leave from the facility for a week prior to that and that they had not been contacted by phone. The DON revealed that, when they returned from leave on (MONTH) 26th, the DON immediately ordered NA-J to leave the facility. Then the DON contacted the agency that NA-J worked for and terminated their contract. The DON revealed that NA-J would not be allowed to work in the facility. Interview with the facility Administrator on 11/03/2016 at 4:26 PM revealed that the administrator was aware of incidences with NA-[NAME] The administrator revealed that NA-J had been rough and mean with some of the residents. The facility administrator revealed that there was no documentation that an investigation into the allegations regarding NA-J had occurred and the administrator revealed the state agency had not been contacted about the allegations. The facility administrator revealed that NA-J was terminated on 10/26/2016 at 4 PM and there had been no prior corrective action taken to address the allegations of abuse regarding NA-[NAME] The facility administrator revealed that it was the expectation that the staff let the DON and administrator know right away if there are allegations of abuse. Review of the nursing staff schedule for (MONTH) (YEAR) revealed documentation that NA-J worked on (MONTH) 13, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, and 26, providing direct resident care for 12 days after allegations of abuse were first reported. Interview with the DON on 11/03/2016 at 3:00 PM revealed that it was the expectation that, if there is an allegation received that a staff member has been rough with or abusive to a resident, that staff member would immediately be removed from caring for residents. Review of the facility policy titled Abuse and Neglect Policy and Procedure dated 6/5/2008 revealed the following: -It is the policy of this facility that reports of abuse, mistreatment, neglect, and/or misappropriation of resident property be promptly and thoroughly investigated. -An employee witnessing an act in violation of these policies shall report the incident immediately and directly to the Administrator (or, in the Administrator absence, to a designee). -When an incident or suspected incident of abuse is reported, the administrator will appoint a representative to investigate the incident or complete the investigation themselves. -The results of the investigation shall be documented and retained with the report from and maintained in the administrator's office. -Results of the investigation shall be reported to the Department of Health and Human Services within five working days. -All steps shall be taken to protect residents from harm upon alleged abuse and during an investigation. Any staff witnessing abuse shall intervene and report to a charge nurse or supervisor of their suspicions immediately. -If the preliminary findings indicate probable abuse/neglect the accused employee may be, and in the case of physical abuse, will be placed on suspension without pay and/or terminated and required to vacate the premises until final disposition of the case. a. If the charges are not substantiated, the suspended employee will be reinstated. b. If the charges are proven correct, termination of the accused employee shall take place with appropriate documentation in the employee's personnel file. The Administrator shall document any variance from this action. -All alleged staff to resident violation and all substantiated incidents shall be reported to the state agency and all other agencies required. The law enforcement agency and/or Abuse-neglect hot line and the Nebraska DHHS shall be notified within 24 hours of a report of abuse or neglect if preliminary finding indicate potential abuse or neglect. |
2020-02-01 |