cms_OR: 32
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 32 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2019-05-06 | 600 | D | 1 | 1 | 9QV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure resident safety for 3 of 6 sampled residents (#s 39, 285, 286) reviewed for abuse. This placed residents at risk of being abused. Findings include: 1. Resident 285 was admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. A 2/3/19 facility investigation revealed Resident 285 was in the main dining room when she/he became agitated. Resident 285 hit Resident 85 three times before staff intervened. While staff moved Resident 285 to her/his room, she/he reached out and hit Resident 48 in the hallway and called her/him a derogatory name. The investigative report revealed Resident 85 indicated she/he was not hurt but never wanted to speak to Resident 285 again. The report revealed Resident 48 indicated she/he was not hurt and did not want to be near Resident 285. A physician order [REDACTED]. Resident 285's 12/2018 Admission MDS Assessment Section C: Cognitive Pattern coded her/him to have a Brief Interview for Mental Status (BIMS) score of 05 out of 15 (severe cognitive impairment). Resident 85's 1/2019 Quarterly MDS Assessment Section C: Cognitive Pattern coded her/him to have a BIMS score of 14 out of 15 (cognitively intact). Resident 285 was care planned with interventions for physical aggression towards others. The interventions included: - Administer medications as ordered; - Provide rest, toileting assistance, pain medication, favorite snack or activities of interest when behaviors occur; - Removing resident from the situation to a quiet setting, resident should not be left unattended, keep her/him in the line of sight prior to meals. A 2/3/19 progress note revealed Resident 48 denied pain as a result of the altercation, but she/he would not dine with Resident 285. Resident 48's 3/2019 Quarterly MDS Assessment Section C: Cognitive Pattern coded her/him to have a BIMS score of 15 out of 15 (cognitively intact). On 5/1/19 at 11:01 AM Resident 48 stated she/he was hit by Resident 285 while in the hallway. Resident 48 acknowledged the incident occurred on 2/3/19. Resident 48 indicated she/he was not hurt from being hit but her/his feelings were hurt when Resident 285 called her/him mean things. Resident 48 stated she/he stayed away from Resident 285 after the incident and indicated she/he did not want to be hit or called names in her/his home. Resident 85 was discharged in 3/2019. On 5/2/19 at 4:46 PM Staff 18 (CNA) stated Resident 285 had a history of [REDACTED]. Staff 18 stated Resident 48 indicated she/he did not want to be near Resident 285 after the incident on 2/3/19. On 5/3/19 at 2:22 PM Staff 10 (RN) acknowledged Resident 285 hit and made obscene comments to Residents 48 and 85 on 2/3/19. Staff 10 indicated Residents 48 and 85 were not physically hurt and neither wanted to be around Resident 285 anymore. On 5/6/19 at approximately 10:00 AM Staff 35 (RCM) acknowledged Resident 285 had a history of [REDACTED]. Staff 35 stated Resident 48 was afraid she/he would be hit again. On 5/6/19 at 12:23 PM Staff 1 (DNS) was informed of surveyor investigative findings regarding the incident on 2/3/19. Staff 1 requested additional staff interviews be conducted. On 5/6/19 at 3:12 PM Staff 28 (CNA) stated Resident 285 had it out for anyone who was overweight. Staff 28 acknowledged the incident on 2/3/19 and indicated Resident 285 called Resident 48 a derogatory name and told her/him to feed your face more. Staff 28 stated she witnessed Resident 48's face become bright red with embarrassment as she/he looked around the dining room which was full of residents. 2. Resident 39 readmitted to the facility in 5/2018 with [DIAGNOSES REDACTED]. Resident 39's 3/2019 Quarterly MDS revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (cognitively intact). Resident 286 readmitted to the facility in 2/2019 with [DIAGNOSES REDACTED]. Resident 286's 2/2019 Annual MDS coded the resident had a BIMS score of 15 out of 15 (cognitively intact). The 2/10/19 Resident/Resident incident report revealed the following: *Incident Description: - Resident 286 and Resident 39 were in a physical altercation; - Resident 286 punched Resident 39 and Resident 39 returned punches; - Resident 286 had a 3.5 cm by 2 cm puffy area to her/his left eye, a 2 cm by 1 cm bump to the left side of her/his head and a 1 cm by 0.5 cm red area under the right eye; - Resident 39 had a bruise on the top of her/his hand that was 7.5 cm by 3.5 cm and a 5.5 cm by 2 cm red area to the front right shin; *Witness statements: - Staff 27 (RN) stated when she returned from lunch Staff 34 (CNA) waved to her for help and that was when she saw Resident 286 and Resident 39 punching each other. Staff 27 stated she tried to separate them and Staff 7 (CMA) also came to help separate the residents. Staff 27 stated she called 911 because they could not separate the two and while on the phone to 911 the two residents stopped fighting. - Staff 7 stated she was not present at the beginning of the fight but saw the residents fighting. Resident 39 was behind Resident 286 and was hitting her/him in the head. Staff 7 stated she and Staff 27 could not get them separated and Staff 27 called the police. The residents stopped fighting on their own. - Staff 34 stated she was at the nurses' station when she heard Resident 286 say to Resident 39 ok fat boy what are you going to do now? and Resident 286 came toward Resident 39 and swung at her/him. Staff 34 stated she waved for help and Staff 27 came to help and they could not separate the two. Staff 27 called the police. The residents stopped fighting on their own. Staff 34 stated she heard Resident 286 cussing loudly earlier when she/he was talking to Resident 10. - Resident 10 stated Resident 286 and Resident 39 started arguing during smoke break related to waiting for pain medications. Resident 39 complained about Resident 286 and Resident 10 went and told Resident 286. Resident 286 cursed loudly at Resident 39 and Resident 10 reported she/he left and did not witness any additional interactions. Staff 34 was unable to be reached for an interview. Resident 286 was no longer a resident at the facility. On 5/2/19 at 10:20 AM Resident 10 refused to be interviewed. In an interview on 5/2/19 at 10:22 AM Resident 39 stated she/he and Resident 286 got into a fight due to a spontaneous issue. Resident 39 stated she/he was under a lot of stress due to unrelated issues and the fight just happened. Resident 39 stated she/he and Resident 286 had a verbal exchange and then hit each other. Resident 39 stated staff came immediately and staff could not have stopped them from fighting. In an interview on 5/2/19 at 4:07 PM Staff 1 (DNS) stated Resident 286 and Resident 39 were both alert, oriented and mobile. Staff 1 stated she learned from Resident 10 that Resident 286 and Resident 39 exchanged words during smoke break on 2/10/19. Later on 2/10/19 Resident 286 and Resident 39 engaged in a physical altercation, staff responded immediately but were unable to separate them and the police were called. The residents self-separated and the police took no action. In an interview on 5/3/19 at 8:50 AM Staff 7 verified the statement she provided in the incident report. Staff 7 also stated Resident 286 and Resident 39 had no prior history of fighting. In an interview on 5/6/19 at 12:15 PM Staff 19 (Administrator) stated she expected residents to be free from abuse. | 2020-09-01 |