cms_OR: 65
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 65 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 600 | D | 1 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure a resident was free from verbal abuse for 1 of 6 sampled residents (# 61) reviewed for abuse. This placed residents at risk for verbal abuse. Findings include: The facility's 6/2018 Abuse Prevention policy indicated abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual of goods and services that are necessary to maintain physical, mental and psychosocial well-being. Abuse includes verbal and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's 8/22/18 Annual MDS revealed a BIMS (Brief Interview for Mental Status) score of 99, which indicated she/he was unable to answer any of the interview questions. An 8/22/18 Cognitive Loss/Dementia CAA revealed the resident's cognitive decline and confusion increased her/his dependence on others and made it difficult to communicate her/his health and safety needs. According to complaint intake information, an 11/6/18 incident of verbal abuse by a CNA toward a resident was reported to the Oregon State Board of Nursing (OSBN) on 11/16/18 (ten days after the incident). OSBN subsequently forwarded the concern to Adult Protective Services (APS) and they notified the nursing facility survey unit. On 12/11/18 at 11:31 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) identified Resident 61 as the resident involved in an incident with a staff member related to verbal abuse on 11/6/18. Resident 61's record revealed no documentation of the incident regarding verbal abuse from a staff member, an assessment of the resident's status or ongoing monitoring after the incident. On 12/11/18 at 1:09 PM Staff 1 provided an investigation of the 11/6/18 incident between Resident 61 and Witness 7 (Former CNA). The investigation began with a staff report of the event on 11/7/18 at 2:50 pm (almost one day after the incident occurred). There was no specific documentation regarding Resident 61's status and the primary focus of the investigation was on the termination of Witness 7's employment. On 12/12/18 at 11:22 AM Staff 1 provided additional information regarding the 11/6/18 incident, including documentation of staff interviews who were present or nearby when the incident occurred with Resident 61. There was no information describing the resident's status during or after the incident nor interviews with other residents who may have had contact with Witness 7. On 12/12/18 at 3:33 PM Staff 31 (CNA) stated she was seated with Resident 61 when Witness 7 attempted to remove Resident 61's drink and the resident refused to let go of the container. Staff 31 further stated Witness 7 stated to Resident 61 she/he should just die. Staff 31 said she reported the incident to Staff 16 the next day. Staff 31 stated there were complaints about Witness 7 by other residents prior to this incident but she did not know if they were reported. On 12/13/18 at 4:19 PM Staff 32 (CNA) confirmed she was on duty the night of the incident between Witness 7 and Resident 61. Staff 32 stated she was in a resident room, heard screaming and when she came out of the room Witness 7 was talking loudly to Resident 61 saying she/he needs to die. Staff 32 further stated when she approached the resident she/he appeared angry and her/his body language was tense after the exchange with Witness 7. On 12/16/18 at 5:17 PM Staff 33 (CNA) stated on 11/6/18 she heard loud voices and yelling in the dining area before she observed Resident 61 and Witness 7 struggling with a drink container. Staff 33 stated Witness 7 was talking very loudly telling the resident no repeatedly and you need to die, you need to be slapped and she also used foul language toward the resident. Staff 33 said she and other staff were able to move the resident to a quiet spot and Witness 7 left the area. Staff 33 stated she thought Witness 7's words got to the resident in spite of her/his confusion because she/he had her/his eyes down and looked sad after the incident was over. On 12/17/18 at 10:55 AM Staff 1, Staff 15 (Administrator) and Staff 16 acknowledged the need to ensure incidents of abuse involving residents were properly reviewed, investigated and reported. According to the 11/7/18 investigation, Witness 7 was not scheduled to work on 11/7/18 or 11/8/18. On 11/9/18 Staff 16 informed Witness 7 she was placed on paid leave until further notice and resolution of the investigation. | 2020-09-01 |