| 49 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2018-03-14 |
610 |
E |
0 |
1 |
YN7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to thoroughly investigate incidents of resident to resident abuse and report the results of those investigations to the Licensing Authority within 5 days for 7 (R #s 33, 62, 79, 87, 93, 97, and 108) of 7 (R #s 33, 62, 79, 87, 93, 97, and 108) residents reviewed for abuse. This deficient practice has the potential to prevent staff from determining the cause of the incident, identifying the need for staff training and implementing needed changes to prevent resident to resident abuse. The findings are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercation with alleged abuse: 1. 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 was lying on the floor. 2. 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. 3. On 01/12/18, Resident 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. 4. 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. Resident (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. 5. 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. 6. 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 residents wrist. 7. 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. 8. 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 then attempting to pull her to standing position. B. On 03/08/18 at 11:05 am, the Administrator was asked to provide the internal investigations for the suspected incidents of resident to resident abuse for: 09/30/18, 10/28/17, 02/13/18, 02/09/18, 01/12/18, 01/14/18, 01/22/18, and 01/31/18. C. On 03/08/18 at 11:49 am, during interview the Administrator provided 3 documents for the internal investigations: 1. RN (registered nurse) #3 stated, In reference to incident on unit 100 from a few days ago, Sep 30, (YEAR), after reflection, I have come to the conclusion that the resident in question was responding behaviorally, and was not acting with malice toward the other resident. 2. Handwritten statement not dated states, To whom it may concern, this nurse went into room [ROOM NUMBER] and found (Name of R #62) on the floor. (Name of R #97) had his hand on his wrist. (Name of R #97) was not agitated or angry. He was easily redirected. Both residents were separated and redirected. 3. A skin integrity report for R #79 not dated, stated No skin impairment. 4. The Administrator did not provide any other documentation showing that investigations were completed on any of the incidents in question. The Administrator verified that she does not document interviews or the findings of investigations. D. Record review of the two reported incidents on 02/09/18 and 02/13/18, revealed no documentation showing that interviews were conducted with staff to determine what happened before the incident, resident behaviors before, during and after the incident, residents expressions or signs of aggression or fear or if there were witnesses. |
2020-09-01 |