| 6414 |
LYONS LIVING CENTER |
285301 |
1035 DIAMOND STREET |
LYONS |
NE |
68038 |
2018-05-10 |
600 |
K |
1 |
0 |
2CLY11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Licensure Reference Number 175 NAC 12-006.05(9) Based on observation, record review and interview; the facility failed to protect residents from residents with adverse behaviors. This affected all residents (Residents 1, 2, and 10) who were residing on the Memory Support Unit (an enclosed wing or hallway which specializes in care of residents with dementia or [MEDICAL CONDITION]). The sample size was 14 and the facility census was 23. Findings are: A. Review of the facility policy titled Preventing Resident Abuse dated 12/13/16 revealed a facility goal to achieve and maintain an abuse free environment. The abuse prevention/intervention program included the following: -assisting or rotating staff working with difficult residents; -training staff to understand and manage a resident's verbal, physical and sexual aggression; -assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict; -assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behaviors; -involving qualified psychiatrists and other mental health care professionals to help the staff manage difficult or aggressive residents; and -striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met. B. Review of the facility policy Resident to Resident Altercations dated 12/13/16 revealed all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Director of Nursing (DON) and the Administrator. If 2 residents are involved in an altercation the staff will: -separate the residents and institute measures to calm the situation; -identify and implement interventions to prevent reoccurrence; -update the resident's care plans; and -report the incident and corrective measures to the appropriate state agencies. C. Review of the facility policy titled Protecting Residents during Abuse Investigations dated 12/13/16 revealed if the alleged abuse involves another resident, the accused resident's representative, and Attending Physician were to be informed of the incident. In addition, the accused resident was to be restricted from visiting other resident's rooms. Within 5 working days of the alleged incident, the facility was to give the state agency a written report of the findings of the investigation and a summary of corrective action taken to prevent the incident from recurring. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/7/18 revealed the resident was admitted on [DATE] from an acute care hospital. The resident's cognition was severely impaired and the resident had a behavior of wandering identified. The wandering placed the resident at significant risk for getting into a potentially dangerous area but did not significantly intrude on the privacy of other residents. The MDS identified a [DIAGNOSES REDACTED]. Review of the resident's undated current Care Plan revealed the resident had impaired decision making skills with memory loss related to a [MEDICAL CONDITION] from a suicide attempt in (MONTH) of (YEAR). The resident had poor decision making skills with a short attention span and made occasional inappropriate comments. No interventions were identified on the residents' plan of care related to cognitive loss or the resident's occasional inappropriate comments. Review of Resident 1's Nursing Progress Notes revealed the following: -2/28/18 at 12:43 PM, (late entry for 2/27/18) the resident was admitted to the Memory Support Unit. The resident was exit seeking but redirected easily. -3/5/18 at 4:56 AM, the resident was wandering in the Unit with an occasional attempt to exit seek. -3/7/18 at 7:45 AM, the resident approached the Nurse's Station and asked if the nurse wanted to have sex. Behavior was easily redirected. -3/19/18 at 3:00 AM, the resident was found in the resident's room with Resident 2. Resident 2 was seated on the side of the bed and Resident 1 was on knees, in an inappropriate position between Resident 2's legs. Both residents were covered with a blanket. The residents were immediately separated and the DON was notified of the incident. Review of Resident 1's medical record revealed no evidence the resident's care plan had been updated regarding the inappropriate sexual behaviors and/or new interventions developed to address the resident's behaviors. Review of Resident 1's Nursing Progress Notes revealed the following: -3/29/18 at 5:20 AM, the resident was making perverted, sexually inappropriate comments to the staff. -4/5/18 at 6:13 AM, the resident has made sexual comments to the staff, asking if staff was a virgin. The resident later came out of the resident's room with the resident exposed and asked the staff member if the resident could stick it up the staff's ass. -4/7/18 at 11:00 PM, the resident was thrusting hips behind a staff member's back. -4/9/18 at 2:40 AM, the resident pulled pants down below buttocks and stated come on to the staff. -4/10/18 at 5:06 AM, the resident came up to staff and stated I want to [***] you. -4/11/18 at 3:30 AM, the resident asked staff if the resident could stick it up the staff member's ass. -4/12/18 at 4:17 AM, the resident was identified as making sexual comments to the staff. Resident asked to eat out the staff member. -4/12/18 at 5:38 PM, the resident asked staff repeatedly about whether or not the staff member was a virgin. -4/12/18 at 6:00 PM, the resident answered the phone on the Memory Support Unit. Staff removed the phone from the resident. The resident then asked if the resident could f--k (obsenity) the staff member in the butt. -4/12/18 at 8:32 PM, the resident had been sexually harassing the staff throughout the shift. The resident came out of the resident's room exposed. The resident asked staff if the resident could f--k (obsenity) staff in the ass. The resident continued to make sexually inappropriate comments and threw a plastic cup at staff. -4/13/18 at 12:45 AM, two Nursing Assistants (NA) entered the Memory Support Unit to assist with rounds. The resident came up behind one of the staff members, placed a hand over the staff member's mouth and used the other arm to grasp the staff member's body and to pull staff up against the resident. The staff member exited the Unit when released and refused to return. -4/13/18 at 4:48 AM, the resident asked staff if the resident could f--k (obsenity) the staff member in the ass. -4/13/18 at 5:13 AM, the resident continued to make sexual comments and gestures to the staff. The resident became angry when the staff attempted to redirect. -4/13/18 at 8:08 PM, the resident swatted the staff's backside 3 times throughout the shift. An appointment was made with the resident's primary physician. -4/16/17 at 3:50 PM, the resident was identified as asking staff inappropriate, sexual questions, requesting sex and inappropriately touching staff on multiple occasions. On 4/18/18 at 3:15 PM a facsimile (fax) was sent to the resident's physician to notify of the sexually inappropriate behaviors toward the staff. The fax indicated the resident had covered a staff member's mouth after coming up behind the staff and was then humping the staff member. The fax further indicated this had happened numerous times. An order was received for [MEDICATION NAME] (medication used to treat anxiety and depression) 300 milligrams (mg) three times a day to help control inappropriate behaviors. Review of Nursing Progress Notes revealed the following: -4/18/18 at 4:26 PM, the resident was kicking the window. The resident identified a desire to get out of the facility. The resident was exposed and asked staff if the resident could stick it in the staff member's vagina. -4/19/18 at 1:48 AM, the resident continued to make sexually inappropriate comments and walked around exposed. -4/20/18 at 1:50 AM, the resident was identified as having 2 episodes of sexually inappropriate behaviors throughout the shift. -4/20/18 at 2:40 PM, the resident continued to display sexually inappropriate behaviors throughout the shift. -4/21/18 at 5:44 AM, the resident came out of room without wearing any pants or underwear. -4/21/18 at 12:30 PM, the resident was identified as having inappropriate behaviors and the resident's physician ordered the resident to be placed in Emergency Protective Custody (EPC-part of the mental health commitment act which permits law enforcement officers to take into custody a mentally ill, dangerous person that is likely to harm themselves or others before a mental health commitment hearing can be held). The resident was taken to Oakland Mercy Hospital. Review of a Nursing Progress Note dated 4/27/18 at 7:00 AM revealed the resident was readmitted to the Memory Support Unit. New interventions were identified to have 2 staff working in the unit at all times and for staff to provide and document every 15 minute checks of the resident. Review of Resident 1's Nursing Progress Notes revealed the following: -4/30/18 at 11:15 PM, the resident attempted to open the exit door and when the door would not open, the resident exposed self and walked through the hallway. -5/1/18 at 12:05 PM, the resident came out of the resident's room and asked staff can I f--k (obsenity) you?' and can you f--k (obsenity) me?. -5/1/18 at 2:00 AM, the resident came to the Nurse's Station and told staff it's time to f--k (obsenity). -5/1/18 at 2:08 AM, the resident was in the bathroom. The resident began to yell out for the staff. When asked what the resident needed the resident responded your pussy. -5/1/18 at 4:00 AM, the resident came out of the resident's room completely naked. -5/1/18 at 5:04 PM, an order was identified for the resident to receive psychiatric evaluation at Fremont Behavioral Health and for psychiatric counseling. -5/2/18 at 5:48 PM, The resident and another resident were discovered by staff about to fight with each other. No physical altercation occurred. After being redirected from the other resident, Resident 1 came up behind a staff member and asked staff if they wanted to f--k (obsenity). Resident redirected to room but remained in the hallway with hands in the resident's pants and touching self. -5/3/18 at 4:20 AM, the resident was at the Memory Support Nurse's Station completely naked. -5/5/18 at 11:35 PM, resident was walking around unit with no pants and private area exposed. Review of the resident's medical record from 5/1/18 through 5/8/18 revealed no evidence an appointment had been scheduled for a psychiatric evaluation or that the resident had received any psychiatric counseling despite the resident's continued behaviors. Review of Resident 1's Nursing Progress Notes revealed the following: -5/9/18 at 5:06 AM, the resident asked the staff do you want to f--k? (obsenity) -5/9/18 at 1:41 PM, the resident asked staff if resident could see the staff's pussy. The resident was redirected and told this was an inappropriate comment. The resident then stated let me stick it in your ass. -5/9/18 at 4:06 PM, the resident told staff all you need to do is open your legs or bend over. E. Review of Resident 2's MDS dated [DATE] revealed the resident had short and long term memory loss with severely impaired decision making skills. The resident had behaviors which included hallucinations and wandering. But wandering did not place the resident at significant risk of getting to a potentially dangerous place and wandering did not intrude on the privacy of others. The resident had [DIAGNOSES REDACTED]. Review of Resident 2's undated current Care Plan revealed the resident could become angry or anxious at times related to Alzheimer's dementia. An intervention was developed to document all behaviors and mood issues and to keep the charge nurse updated. Review of Resident 2's Nursing Progress Notes dated 3/19/18 at 3:45 AM revealed the resident was found in the room of another resident on the Memory Support Unit at 3:00 AM. Resident 2 was seated on the edge of the bed and Resident 1 was on knees in an inappropriate position between Resident 2's legs. A blanket covered both of the residents. The blanket was removed and the residents were separated. Review of facility investigations of potential abuse/neglect from 12/1/17 to 4/1/18 revealed no investigation had been completed regarding the incident which had occurred between Resident 1 and Resident 2 on 3/19/18; the incident had not been reported and no interventions were put into place to protect Resident 2 from any potential ongoing sexual abuse. Review of a facility investigation dated 4/26/18 revealed on 4/21/18 at 11:58 AM, the staff had walked into a vacant room on the Memory Support Unit and had found Resident 1 and Resident 2 with their pants down and with their perineal area fully exposed. Resident 1 was holding Resident 2 in a bent over position so the resident's torso was on the bed. Resident 1 was attempting to have anal sex with Resident 2. Resident 2 appeared frightened and Resident 1 was resistive when the staff attempted to remove the resident from the situation. The report indicated Resident 1 had a recent increase in sexual comments towards the staff but had displayed no sexual tendencies toward other residents. An order was received for Resident 1 to be EPC'd and staff remained with Resident 1 until the police arrived. The resident was taken to Oakland Mercy Hospital and then to the Lancaster Mental Health Crisis Center. The resident returned to the facility on [DATE] and was readmitted to the Memory Support Unit. New interventions were identified for staff to provide and to document every 15 minute checks on Resident 1. Resident 1 was to be seen by a psychiatrist and was to receive counseling. In addition, the facility was to pursue more appropriate placement for Resident 1. Review of a Nursing Progress Note for Resident 2 dated 4/27/18 at 10:50 AM revealed staff were made aware that Resident 1 was to be readmitted . Staff to complete and document every 15 minute checks of the residents. The resident's family was notified and indicated they would trust the facility to make sure Resident 2 was not in any danger. F. Review of Resident 10's MDS dated [DATE] revealed the resident's cognition was severely impaired. The resident had behaviors which included resistance with cares and wandering and had [DIAGNOSES REDACTED]. Review of Resident 10's undated current Care Plan revealed the resident had cognitive loss due to [DIAGNOSES REDACTED]. Review of staff documentation related to the 15 minute checks of the residents on the Memory Support Unit revealed the following on 5/2/18: -9:30 AM, Resident 10 walked into Resident 1's room. Resident 1 told Resident 10 to get out. Resident 10 refused and Resident 1 stated, I will punch you and drew back fist. The residents were separated by the staff. -11:00 AM, Resident 10 was standing in the doorway to Resident 1's room. Resident 1 was at the end of the hallway, saw Resident 10 outside of room and came down the hallway with fists drawn. The residents were again separated. Review of a Nursing Progress Note for Resident 10 dated 5/2/18 at 5:55 PM revealed the resident tried to get into a physical altercation with another resident. G. Observations of the Memory Support Unit on 5/7/18 from 9:00 AM to 12:30 PM revealed the following: -9:07 AM, Resident 1 was lying on the resident's bed with eyes closed. Resident 10 entered the resident's room and stood next to Resident 1's bed. -9:11 AM, NA-B entered Resident 1's room and led Resident 10 away from Resident 1's bed. NA-B assisted Resident 10 to the bathroom in Resident 10's room. NA-B closed the door to Resident 10's room while assisting the resident with toileting. NA-B was unable to visualize Resident 1 and Resident 2 and no other staff was available on the unit. -9:11 AM, Resident 2 ambulated out of the dining room and into Resident 1's room and closed the door. -9:11 AM to 9:22 AM, Resident 1 and Resident 2 remained in the room with the door closed. NA-B remained in Resident 10's room with the door closed. -9:22 AM, NA-B exited Resident 10's room and looked in the dining room and then in the corridor for Resident 2. NA-B opened the door to Resident 1's room and assisted Resident 2 out of the room. NA-B closed Resident 1's room door. NA-B led Resident 2 to the Living Room area and placed a movie on the television for Resident 2 to watch. -9:22 AM, Resident 10 entered Resident 1's room and closed the room door. -9:25 AM, Resident 10 opened the door to Resident 1's room but remained in the doorway of the room. Resident 10 glanced up and down the corridor, re-entered Resident 1's room and again closed the room door. NA-B remained in the Living Room with Resident 2. No other staff was available on the Memory Support Unit to monitor the residents. -9:29 AM, NA-B approached Resident 10's room and when unable to locate Resident 10, opened the closed door to Resident 1's room. Resident 10 was again assisted out of Resident 1's room and was taken into the Living Room to watch a movie with Resident 2. -9:30 AM to 12:30 PM, NA-B was the only staff member working on the Memory Support Unit. During an interview on 5/7/18 from 1:30 PM to 2:00 PM, NA-B identified the following: -Resident 1 started having an increase in sexual behaviors about 2 weeks after the resident was admitted to the facility; -when Resident 1 was re-admitted on [DATE] the Memory Support Unit was to be staffed with 2 Nurse Aides. However, the facility is short staffed and after the first couple of days, there has never been more than 1 Nurse Aide at a time scheduled on the unit; -staff are to complete and document every 15 minute checks on Resident 1, Resident 2 and Resident 10. These are the only residents on the unit; -staff have been instructed to keep Resident 2 and Resident 10 out of Resident 1's room. However, both residents try repeatedly each day to gain access and it takes up the whole day just redirecting the residents; -Resident 2 requires 1-2 staff for an every 2 hour check and change schedule for incontinence; -Resident 10 requires cues and assistance every 2 hours for toileting and incontinence cares; and -when assisting Resident 2 or Resident 10 with cares, there is no one available to monitor the remaining residents to assure no abuse occurs. During an interview with the Provisional Administrator on 5/7/18 from 2:00 PM to 2:30 PM the following was confirmed: -incident on 3/19/18 at 3:00 AM between Resident 1 and Resident 2 was not reported or investigated and this incident occurred prior to the current Administrator and DON's start dates and both were unaware of the incident. -no interventions were developed or implemented to protect Resident 2 after the incident which occurred on 3/19/18; -Resident 1 had escalating sexual behaviors directed at the staff. The resident made inappropriate sexual comments, exposed self and touched staff inappropriately; -on 4/21/18 Resident 1 was found with Resident 2 in an empty room on the Memory Support Unit. Both residents were exposed and Resident 1 was attempting to have anal sex with Resident 2; -the resident's physician was notified and an order was received for the resident to be EPC'd. -the resident was taken to Oakland Mercy Hospital and was evaluated in the emergency room . The resident was found to be medically stable and was cleared to return to the facility. -the facility felt they were unable to meet the resident's needs as not enough staff available to have 1:1 with the resident. The resident's family drove the resident from Oakland Mercy Hospital to Lincoln per request of the Administrator and was to be admitted to Bryan East Medial Center for an inpatient psychiatric evaluation; -upon arrival in Lincoln the family contacted Bryan Medical Center who indicated no availability for the psychiatric evaluation and refused to admit the resident; -the resident was taken home with the family until the resident had inappropriate sexual behaviors with a minor child in the home; -the resident was then taken to the Lancaster Mental Health Crisis Center by the police where the resident remained until he was readmitted to the facility on [DATE]; -with the residents readmission the facility was to ensure 2 staff were scheduled for the Memory Support Unit at all times and staff were to conduct and document every 15 minute checks on the residents; -Resident 1 continues to have inappropriate sexual behaviors; -the facility was unable to schedule 2 staff at all times for the unit as not enough staff were available; -as of 5/7/18 the facility had not made an appointment for Resident 1 to be seen for Psychiatric Evaluation or an appointment made for the resident to receive counseling; and -was unaware of the resident to resident altercation between Resident 1 and Resident 10 on 5/2/18 and no further interventions had been into place to maintain the residents safety and to protect the residents from potential abuse. G. ABATEMENT STATEMENT Based on the following, the facility removed the immediacy of the situation and the Immediate Jeopardy situation was abated: 1). Memory Support Unit to have 2 staff members scheduled around the clock. One of the staff assigned to the Unit was to be with Resident 1 at all times. If the other staff member needed assistance with completing cares for Resident 2 or 10, then they needed to call off the Unit for a third staff member. 2). New form was developed for the staff to document the 15 minute checks on the residents. The Form must be used by all the staff on the Unit and must be filled out completely each shift. 3). Education provided to all staff working on the Memory Support Unit to assure the staff's safety when working with Resident 1. Education included the following: -never turn your back to Resident 1; -always carry a walkie-talkie with you to maintain communication with other staff; -Charge Nurse to check on staff working on the Unit every hour; and -if feeling threatened to immediately call for help. 4). Nursing schedule completed to assure adequate coverage for the Unit. 5). Resident was seen by Advanced Practice Nurse Practitioner on 5/9/18 with a new order for [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorders) 5 mg at bedtime. The immediacy had been removed, however, the deficit practice was not totally corrected. Therefore, the scope and severity was been lowered to an E. |
2019-03-01 |