cms_OR: 68
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 68 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 610 | F | 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 investigations for allegations of abuse were thoroughly investigated for 5 of 6 sampled residents (#s 7, 36, 42, 61 and 423) reviewed for abuse. This placed residents at risk for continued abuse. Findings include: 1. Resident 36 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 10/19/18 MDS indicated Resident 36 was cognitively intact. The resident's current Personalized Bedside Care Plan indicated the resident was incontinent of bowel and bladder and two staff were required to assist the resident with bed mobility. One staff was to stand directly in front of the resident when the resident was assisted to roll in order to reassure she/he would not roll out of bed. The 11/8/18 Investigation by Staff 1 (DNS) indicated Resident 36 reported Witness 2 (Former CNA) touched me. Whenever he is changing me, he feels me up. Resident 36 further reported the female CNAs giggled when Witness 2 touched her/him and did not intervene. The resident reported the incident occurred the other day. Resident 36 did not provide the female CNA's names. Staff who worked with Witness 2 were interviewed and Staff 1 ruled out abuse. The investigation did not include documentation to indicate additional residents were interviewed to ensure Witness 2 did not inappropriately touch other residents. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS), Staff 1 indicated she interviewed staff regarding Witness 2's interactions with residents but did not interview additional residents. Staff 1 further indicated Witness 2 submitted his resignation in (MONTH) (YEAR), no longer worked at the facility and was not interviewed. 2. 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. 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 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 (DNS) provided additional information regarding the 11/6/18 incident. There was no documentation of Resident 61's reaction to the incident or how she/he was kept safe following the incident. There were not interviews with other residents who may have had contact with Witness 7. On 12/17/18 at 10:55 AM Staff 1, Staff 15 (Administrator) and Staff 16 acknowledged incidents of resident abuse must be thoroughly thoroughly investigated, including interviews with other residents and ensuring the resident who was affected was kept safe. 3. Resident 423 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Resident 42 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. An Event Overview dated 8/7/18 revealed Resident 423 was exhibiting agitation and verbal behaviors. Resident 423 suddenly slapped Resident 42 on the upper abdomen causing Resident 42 to be startled and yell out. Review of Resident 423's and Resident 42's records revealed no documentation of a thorough investigation of the 8/7/18 incident. There were no interviews of staff or other residents who may have been present when the incident occurred. On 12/13/18 at 3:26 PM Staff 1 (DNS) and Staff 15 confirmed the investigation was not thorough and lacked interviews with staff or other residents who may have been present or interacted with Resident 423. 4. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident's 9/12/18 MDS revealed her/his BIMS (Brief Interview for Mental Status) score was 12/15 indicating moderate cognitive impairment. During an interview on 12/13/18 at 4:19 PM Staff 32 (CNA) stated Witness 7 (Former CNA) grabbed the resident and caused bruises when she yanked Resident 7 up in the wheelchair. Staff 32 further stated Witness 7 was rough with other residents in front of staff and visitors. Staff 32 indicated she informed Staff 16 (Assistant DNS) about her concerns with Witness 7. On 12/14/18 at 9:35 AM Resident 7 stated she/he had been treated roughly at times but denied feeling unsafe. There was no documentation of any investigations completed regarding concerns of inappropriate treatment of [REDACTED]. On 12/17/18 at 10:55 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) stated they were not aware of any issues related to Resident 7 and no staff reported any problems. | 2020-09-01 |