| 46 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2018-03-14 |
600 |
H |
0 |
1 |
YN7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents residing on the Dementia (a decline in mental ability severe enough to interfere with daily life) Unit were free from physical abuse for 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) of 8 (R #s 4, 33, 62, 71, 79, 87, 93, and 108) residents reviewed for abuse by failing to prevent R #97 from pushing, slapping, grabbing, and pulling a resident out of bed onto the floor. This deficient practice subjected vulnerable residents to assaults, which are likely to cause serious injury, feelings of fear, distress and humiliation. The findings are: [NAME] Record review of R # 97's Admission record, revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Record review of R # 97's Resident Management System Summary Reports revealed the following resident to resident altercations with/alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The (unidentified) resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and Certified Nurses Aide (CNA) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim (victim) was lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 6. On 01/12/18, Resident (R #97) hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 7. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified male resident), (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Unidentifed female resident replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 8. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 9. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on resident's wrist. 10. On 02/09/18, I heard (R #93) yell out in fear. I ran down to room and found (R #97) standing above (R #93), holding his left leg, jerking it, pulling him off the bed onto the floor, onto the mat next to the bed. (R #93) yelling out in fear. No physical injury noted, but Pt (patient # 93) is very upset. 11. On 02/13/18, Per nurse report, nurse heard yelling from nurses station and when (sic) to check noted this resident (R #79) being pushed by another resident (R #97) into the hall from his room causing her to fall on floor in hallway, nurse noted the other resident, R #97 then attempting to pull her to standing position. C. Record review of R # 97's Psychiatry Note dated 02/05/18, revealed Patient has shown improvement in behaviors with [MEDICATION NAME] (used to treat high blood pressure). Continues to have some agitation with certain residents. He is more easily redirected. D. Record review of R #97's Minimum (MDS) data set [DATE], revealed that he has Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring 4 to 6 days, in the 7 day look back period. R #97 has wandered 4 to 6 days in the 7 day look back. He requires limited assistance with walking and locomotion (how resident moves between locations). He has no physical impairments to his upper and lower extremities (arms and legs) and he does not use any mobility devices (wheelchair, walker, cane). E. Record review of R # 97's Physician order [REDACTED]. Every shift for resident to resident abuse. The orders indicate the following medications are in the process of being gradually reduced or were discontinued: [MEDICATION NAME] (an anticonvulsant) for Dementia and behaviors, [MEDICATION NAME] for agitated behavior related to Dementia, [MEDICATION NAME] for Dementia, agitation, and behaviors, [MEDICATION NAME] (antipsyhotic) for violent psychiatric behavior, severe agitation, restlessness, and [MEDICATION NAME] (antipsychotic) for agitation. F. Record review of the Progress Notes dated 03/19/17 through 03/08/18, revealed the following incidents with R #97: was physically aggressive and/or attempting to hit, choke, push, grab, slap both residents and staff members; 1. On 03/03/18 at 2:18 am, Pt (R #97) was awoken by another Pt. (resident unidentifed) going in his room yelling and looking for her husband. He (R #97) came out with a jolt to his room door. Following the other Pt. (resident unidentifed) into the dining room. 2. On 2/25/18, Resident tried grabbing another resident's (resident unidentifed) arm who sat down at the same table. 3. On 02/21/18, Resident got up to go to the bathroom, CNA assisted him to the bathroom. (R #97) pushed CNA up against the wall when returning to bed. 4. On 02/13/18, during a meeting with (R #97) family, states (R #97) was sent to (name of hospital) to try and have the eval (evaluation ) done, but they were unable to do a med (medication) eval due to his severe dementia. (R #97) has been aggressive with all the family members at one time or another. They understand that he can hurt someone and they don't want him to hurt anyone. His meds will be adjusted so that he is unable to hurt anyone. 5. On 02/06/18, While attempting to redirect resident to his room, he attempted to strike and choke the CN[NAME] Once assisted to his room, resident again attempted to strike and push both nurse and CNA inside resident room. 6. On 02/01/18, Resident with aggressive behaviors throughout afternoon. Not hard to divert but persistent in his attempts to threaten other residents with body language or reaching out with both hands. 7. On 01/28/18, Resident sitting in dining room when he stood up from his chair and attempted to slap another male resident (resident unidentifed) walking by. 8. On 01/16/18, Resident observed standing up to strike another male resident (resident unidentifed) in the face. 9. On 01/15/18, (Name of a behavioral health hospital) called and said that (R #97's) dementia is too severe and he wouldn't be able to participate in their program. 10. On 01/14/18, Female resident (resident unidentifed) had entered resident's room at 5:15 am. Female was overheard stating that she was looking for the restroom. Upon entering the room to direct female resident, the patient charged at her with hands out as if preparing to push her. 11. On 01/11/18, Female resident (resident unidentifed) was standing near sink in dining room when this resident (R #97) walked in and up to her raising his hands towards her. 12. On 01/11/18, Resident attempted to become physically aggressive with (R #4) twice today. Both times (R #4) was just passing by in hallway and (R #97) went after him attempting to grab him while staring him in face. Both times resident (R #97) was intercepted from hitting resident (R #4). (R #4) did nothing to bring on (R #97's) anger. 13. On 01/10/18, Resident in hall at approximately 3:30 am. As I (RN #2) went to investigate the resident had reentered his room and was sitting on the edge of the bed. I entered the room to check on his needs when the resident stood from the edge of the bed and charged at this nurse. Using my hands to fend him off the resident grabbed both my hands in a crushing grip, and started to push wildly at me, and backed me out of the room and into the hall. Where he momentarily stopped his attack. The resident walked back into his room turned around, spotted me in the doorway, and charged at me again. Further review of the progress notes revealed between (MONTH) (YEAR) and (MONTH) (YEAR), R #97 has had 24 attempted incidents of physical aggression such as hitting, choking, pushing, grabbing, and slapping both residents and staff members and 10 incidents of actual physical contact between R #97, other residents, or staff. [NAME] Record review of the care plan updated on 02/09/18, indicated that interventions were being added to the care plan. Some of the new interventions were: 1. Add 1:1 2. Guide resident through the task at hand 3. Make eye contact prior to starting care 4. Provide outdoor activities 5. Monitor medications, especially new/changed/discontinued 6. Observe for non-verbal signs of physical aggression, e.g.,rigid body position, clenched fists H. On 03/08/18 at 9:36 am, during interview the Director of Nursing (DON) stated R #97 Has spatial issues, if you get too close he gets angered more. At night he was roaming more, so we put the 1:1 (one on one/staff to resident) at night. The DON stated that staff should be arms length away at all times a night. I. On 03/08/18 at 9:48 am, during interview the Corporate Compliance Nurse (CCN) stated that R #97 is territorial and reacts when residents get too close. She stated that R #97 used to be able to communicate, but he has declined. She stated that his behaviors are communicating his needs and that R #97 was reacting to situations were he was provoked by other residents. She stated that R #97 was not intending to hurt other residents, but from the reports it seemed like he was concerned for the other person and was trying to help them up. The CCN confirmed that R #97 would push residents away if they got to close to him, went in his room, or sat at the same table. She stated that they increased his behavior management and feels like it has been successful in reducing his behaviors. [NAME] On 03/08/18 at 11:49 am, during an interview the Administrator stated that R #97 reacts because he is usually provoked by residents getting in his space. She stated that if somebody is at his table trying to do something with him, he'll push them. The Administrator stated that his Dementia was increasing, he was no longer verbal. She stated that the interventions they have in place are: to give him space in the dining room, they put a stop sign across his door and another residents door, medication adjustments, put him on extra monitoring, one on one, and stated that she has seen a decrease in his behaviors. The Administrator stated that R #97 has no place else to go and that the residents on the unit are as safe as they can be. The Administrator stated that R #97 does not posses the cognition to have the intention to cause harm to other residents, but that he is reacting to situations were he feels like his space is being invaded. The Administrator verified that R #97 has made physical contact with residents, but that it is not intentional when he pushes them, it is him reacting to the situation. K. On 03/08/18 at 2:09 pm, during an interview the DON stated that she made the decision after discussing with the doctor to put R #97 on one to one monitoring at night because his behaviors were worse. She stated that during the day, she has enough staff working on the unit to monitor him during the day. The DON stated that R #97 hasn't always been aggressive, but that his Dementia is worse and his speech and understanding has declined over the last few months. She stated that she sent him out for an evaluation and has a referral to see a psychiatrist off site and is working to reduce his medications. L. On 03/08/18 at 2:27 pm, during an interview Certified Nursing Assistant (CNA) #10 stated that R #97 will usually get upset when it's meal time and he gets his food. CNA #10 stated that if somebody touches his food, he reacts and pushes people. She stated that he has behaviors at every meal, so they try to pay attention to make sure no one goes around him. She stated that R #97 is tall and strong and states that when he pushes or hits residents, that it's deliberate. M. On 03/09/18 at 10:04 am, during an interview Licensed Practical Nurse (LPN) #1 stated that R #97 has behaviors if people intrude on his space. LPN #1 stated that about a month ago he got confused and pulled another resident out of bed. LPN #1 also stated that it was reported to her that a female resident went into his room and R #97 pushed her out of his room into the hall. She stated there are a lot of other incidents where other residents will approach him, try to hover over him, or take his drinks and that is when he gets defensive. N. On 03/09/18 at 10:56 am, during an interview Registered Nurse (RN) #3 stated, that he thinks R #97 only responds to things in his field of vision. RN #3 stated that he does not see a purpose with any of R #97's behaviors, it's more of a reflex, not intent. RN #3 stated that R #97 Can no longer form the intent. Other than him pushing residents from his bubble, there is no intent involved. He does not have spasms, he does not jerk. When asked if R #97 pushes residents accidentally, RN #3 stated No, it's not that he brushed them accidentally, it's deliberate but not intentional. When asked if R #97 is a danger to other residents, RN #3 stated that was a hard question to answer, but stated He is still very strong. He physically ejected me from his room. RN #3 stated the potential for R #97 to hurt someone is there. O. On 03/12/18 at 4:07 am, during observation and interview CNA #11, was observed in R #97's room doing 1:1 care. CNA #11 stated that she is a little scared because R #97 tries to grab her when he gets up. She stated that when he goes after her, she gets scared but she tries not to show fear because she doesn't want him to become more aggressive. P. On 03/12/18 at 6:05 am, during an interview CNA #12 stated that R #97 was going into other resident rooms and that before the 1:1 he would go straight to R #93's room and pull him off the bed. She stated that R #97 was pulling R #93 off the bed or going into his room often enough that one on one was started. Nobody is safe. We don't know what triggers him. If you happen to be passing by, you're the one that's gonna get it. If you are in his face, it will be faster. She was asked if R #97 was appropriate on the unit, she stated No. She was asked if R #97 is dangerous, she stated To staff and residents. (Name of R #97) is pretty strong. A lot of female staff are afraid of him. He mostly attacks the girly women. Some people (staff doing 1:1) sit in his room, I don't. If it's dark and you startle him, he's going to attack you. He tends to go for strangers. I stay in the hallway because I know he is going to two places, he goes to R #93's room or the dining room. Q. On 03/12/18 6:18 am, during a second interview CNA #11 stated He was really aggressive, so when he comes at you, if you don't run away he will assault you. Since he doesn't speak you don't know what's going on. He stares and he frightens you. When they decided to put him on 1:1 that was when he was always going to one room and pulling the resident out of bed. That was scary, we didn't know what happened. More than two times he was going to the room of a particular resident. I witness (sic) it twice, he (R #93) was yelling and crying and R #97 was standing over him. I was in a room, I just find (sic) the resident on the floor with the bed sheets on the floor. The second time, (R #97) was pulling on his foot. It was scary because you don't know what can happen. CNA #11 was asked if R #97 is dangerous, she stated Yes, because in the dining room, if you leave him alone, he will go and slap all the people. I saw four times (sic) this week already with one woman (R #79). R. Record review of the Abuse Prohibition Policy dated 09/01/16, stated Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following; prevention of occurrences, identification of possible incidents or allegations which need investigation. Purpose: to ensure that center staff are doing all that is within their control to prevent occurrences of abuse and mistreatment for [REDACTED]. |
2020-09-01 |