| 5456 |
GOOD SAMARITAN SOCIETY - WOOD RIVER |
285198 |
1401 EAST STREET |
WOOD RIVER |
NE |
68883 |
2017-03-22 |
223 |
J |
1 |
1 |
HUVK11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05 (9) Based on record review, observation, and interview; the facility failed to ensure residents were not subjected to physical abuse. This violation effected one of five sampled residents, Resident 40. The facility census was 59. Findings are: A review of the Facility's policy and procedure titled ABUSE AND NEGLECT, last revised 11/16, revealed the purpose of the policy was to ensure residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the individual, family members or legal guardians, friends or other individuals A review of the facility's documentation of Investigation of ABUSE, NEGLECT, OR MISAPPROPRIATION dated 2/22/17, revealed that on 2/9/17, Resident 81 was observed by staff to be hitting Resident 40 on the head with a hairbrush. The residents, who resided in the same room on the facility's Special Care Unit (SCU)-for Memory Care, were immediately separated. Resident 81 was sent out to an area Hospital's Behavioral Unit for evaluation and returned to the facility on [DATE] . The outcome of the facility investigation was to continue to monitor Resident 81's interactions with roommate as well as other residents, and make a room change when one was available. A review of Nurses Notes for Resident 40 revealed a note dated 2/9/2017 at 12:41 which documented that the resident was struck with a hairbrush on the resident's head by roommate (Resident 81). Two staff members were in the resident's room when incident occurred. Residents 40 and 81 were immediately separated and no injuries are noted at the time for Resident 40. The documentation indicated that Safety precautions are being advised. Further review of Resident 40's Nurses Notes, dated 2/9-3/5/17, revealed no further documentation related to the incident on 2/9/17 nor interventions which were put into place to ensure Resident 40's safety following readmission of Resident 81. A review of MDS (Minimum Data Set-a mandatory comprehensive assessment tool used for care planning) information for Resident 40 revealed an Annual assessment, dated 1/31/17, which indicated: BIMS (Brief Interview for Mental Status)=03 (scores=00-07 indicate severe impairment), the resident exhibited behaviors not directed at others 1-3 days of the assessment period. Resident 40's behaviors had worsened since the previous review and significantly interfered with the residents participation in activities or social interactions, intruded on privacy/activity of others, and was disruptive to care and the living environment. The resident required: extensive assist of two staff members for bed mobility, transfers, and personal hygiene; extensive assist of one for dressing, eating, and toilet use; walking in room occurred once or twice, walking in corridor was dependent with 1 assist, and a wheelchair was used for most locomotion both on and off the unit. A review of Resident 81's Care Plan printed on 3/6/17 revealed the resident: had impaired cognitive function (dementia or impaired thought processes), had a mood problem of anxiety and major [MEDICAL CONDITION] evidenced by tearful episodes about not being able to go back home, and exhibited behavior symptoms toward roommate and staff. The resident wandered into others rooms. The resident would swear/yell at staff, hit, and use care equipment as weapons by swinging items toward others in a defensive manner. Documented interventions included: provide a structured environment in the SCU, consult with Psychiatric Advanced Practice Registered Nurse (APRN) related to behaviors and use of antipsychotic medications, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention and remove from situation, and offer diversionary activities such as folding towels, dusting, sorting items. Revisions dated 2/22/17 were: continue to monitor interactions with roommate and other residents throughout the day to ensure others' safety, consult with pharmacy and health care provider to consider dosage reduction when clinically appropriate, and redirect with conversation and a walk in the fenced in area of the Special Care Unit if weather permitted . The Care Plan did not include new interventions put into place to protect Resident 81's roommate (Resident 40) from further physical abuse upon Resident 81's readmission on 2/14/17. . An interview on 3/6/17 at 1:30 PM with Nursing Assistant (NA)-DD revealed Resident 40 was dependent upon staff for ADLs (Activities of Daily Living), yelled out/verbalized almost constantly during cares, was unable to voice needs, required a sit/stand mechanical lift for transfers, used tilt in space w/c for locomotion, was assisted with toileting every 2 hrs. and laid down in bed after meals. Continued interview with NA-DD revealed the NA was unaware of any new interventions put into place following the readmission of Resident 81 (Resident 40's roommate) to ensure no further abuse occurred. The NA reported staff were aware of the need for increased supervision in the SCU and tried to keep one staff member in the commons area with any residents who were there. The other scheduled staff member would monitor the hallway and resident rooms. An interview on 3/6/17 at 1:15 PM with Medication Aide (MA)-EE revealed Resident 40 (Resident 81's roommate) was cognitively impaired and dependent upon staff for ADLs. Resident 40 also did a lot of screaming or calling out, which seems to upset Resident 81. The MA reported that since Resident 81 returned to the facility following psychiatric evaluation, some medication changes have been made, and things seem to be better with the resident's roommate. A motion alarm was in place in the room shared by Resident 40 and 81, which alerted staff to when Resident 81 crossed to the roommate's side of the room. The motion alarm was not a new intervention and the MA denied knowledge of new interventions put into place to protect Resident 40 following Resident 81's readmission to the facility and room [ROOM NUMBER]. MA-EE reported that Resident 81 spent a lot of time in the commons area and ambulated independently throughout the Special Care Unit. An observation on 3/6/17 at 1:30 PM revealed room [ROOM NUMBER] was shared by Residents 40 and 81. A motion sensor alarm was noted at the edge of the floor mat near the privacy curtain splitting the room. The Immediate Jeopardy was abated and the severity lowered to a 'D' level in the late afternoon of 3/6/17. The facility assessed all residents that could be at risk for ongoing abuse. The facility interviewed all interviewable residents and also interviewed the family members of non-interviewable residents. Staff were educated on abuse/neglect reporting and protection of residents from abuse situations. Residents were moved to separate rooms and staff monitoring of the aggressive resident was increased to ensure that no other resident was being targeted by the aggressor. The aggressive resident's behavior monitoring plan was revised to include immediate staff interventions for the resident's behaviors. |
2020-01-01 |