| 48 |
DAMAS HOSPITAL SNF |
405023 |
2213 PONCE BY PASS |
PONCE |
PR |
717 |
2017-05-25 |
226 |
L |
1 |
1 |
NJQB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a standard and extended FOSS survey for recertification and a complaint investigation PR 598, review of the facility's grievance and complaint registry, policies and procedures (P&P's), and interviews performed on 5/22, 5/23, 5/24, and 5/25/17 it was determined that the facility failed to prevent patients from harm. This constitutes an Immediate Jeopardy to 13 out of 13 residents (R) admitted at the facility. (R#1 to R#13) Findings include: During the resident #6 complaint investigation performed on 5/24/17 at 10:30 am, the following was found: 1. Resident #6 is a [AGE] years old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident #6 was admitted for physical therapy, occupational therapy and wound care. The resident #6 was discharge home on 5/18/17 at 12:50 pm, having a length of stay of 51 days in the facility. The close record review was performed on 5/25/17 at 2:00 pm. 2. The Resident #6 complaint allegations of 4/6/17 were the following: a. The nursing staff talked to him and treated him in a rude way. b. The nursing staff ignored when he called the nursing station. c. The nursing staff did not come to the room to change him on bed positioning. d. The nursing staff did not assess and manage the pain that the sacral ulcer caused. e. The pain provokes constantly vomit episodes to the resident #6. f. The nursing staff did not come to the room to clean resident #6. 3. During close record review (RR) of Resident #6 on 5/25/17 at 2:00 pm was found the following: a. The Minimum Data Set (MDS) report of 4/4/17 on section G0110. Activities of Daily Living (ADL) Assistance on 5/25/17 at 3:12 pm provides evidence that the resident #6 is total dependent on bed mobility and that includes how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. The resident #6 needs full staff performance every time in bed mobility, one personal physical assist. b. The Minimum Data Set (MDS) report of 4/4/17 on section J0100 Pain Management on 5/25/17 at 3:12 pm provides evidences that the resident #6 is received scheduled pain medication regiment, received PRN pain medication or was offered and declined, pain is suffered occasionally, the worst pain event during the last five days was 8/10 and severe. c. During review of the nursing notes of 4/6/17 was found incongruence between the pain documentation of the nursing staff and what the patient referred. The nursing note provides evidence that the patient did not had pain, however the patient referred that he had such pain that caused him vomiting episodes. d. During review of the nursing notes of 4/6/17 was found evidence that the nursing staff did not included in her note information related of the resident #6 clinical changes and needs. e. During the Change of position form of 4/6/17 provides evidence that the nurse change the patient position at 12:00 am, 2:00 am, 4:00 am, and 6:00 am. However the patient referred that the nursing staff did not perform any changes on position after 1:35 am thru 6:00 am. f. During review of the Facility Re-assessment of Pain form was found evidence that the nursing staff documented the pain scale on 4/6/17 at 12:00 am (0/10), 4/6/17 at 4:00 am (0/10), and 4/6/17 at 6:00 am (5/10). However the resident #6 referred that the nursing staff did not come to the room from 1:35 thru 6:00 am and that he was suffering of pain during that time. g. During review of the Medication record was observed that the patient received [MEDICATION NAME] 5/325 mg 1 tab Oral (PO) every 3 hours when needed (PRN) for pain on 4/3/17 at 9:00 am and 9:50 pm, 4/4/17 at 10:00 am and 5:30 pm, 4/5/17 at 10:00 am and 5:00 pm. However from 4/5/17 at 5:00 pm thru 4/6/17 at 6:00 am (11 hours) the patient did not received medication for pain during eleven hours. The patient referred during interview that he had such pain that caused him vomiting episodes. h. During the medical order reviews was found evidence of a telephone order from the physician of [MEDICATION NAME] 5/325 mg 1 tab PO PRN every 3 hours for pain. The medication was administered on 4/6/17 at 6:00 am. i. During the interdisciplinary group notes was found evidence that RN employee #10 oriented the resident #6 about the importance of position changes every 2 hours and to avoid the pressure on the affected area. j. During review of the nursing care plans was found evidence that the Pain, Fall, and Pressure Ulcer care plans were open. The Pain care plan establishes the following: i. The use of therapeutic modalities for the pain management and pain control like: Positioning. ii. Administer medication according to medical order for pain management. iii. Pain note in clinical file must include: sounds, complaints, facial expressions, and movements. However the resident #6 referred that from 1:35 am thru 6:00am he did not received change of position and pain medications. The Fall care plan establishes the following: i. Provide rounds every two hours to three hours and / or more frequent in patients identified at risk. However the resident #6 referred that the nursing staff did not come to the room from 1:35 am thru 6:00 am. The Pressure Ulcer care plan establishes the following: i. Perform interventions aimed at preventing the development of area and pressure ulcers ii. Promote and reposition every two hours iii. Keep the skin dry, clean and lubricated iv. Educate the resident and family about the treatment of [REDACTED]. However the patient referred that the nursing staff did not reposition him after 1:35 am thru 6:00 am. He also states that he vomited and the nursing staff did not come to the room to clean him. According to telephone interview with the Resident #6 on 5/31/17 at 9:52 am, he stated: I really do not have much to tell because I have nothing against those people. I was complaining of pain and discomfort and the nurses came and treated me roughly. They also told me two comments that were not pleasant and made me feel bad and like I was not welcome. One of the nurses said she would not come to the room until it was 4:00 am. The other nurse said that I had only come to the facility for physical therapy and nothing else. I felt bad and could not move to change my position that already bothered me. I needed to change my position, which would have alleviated the pain a little. The pain became so strong that it made me vomit several times. It was not until 6:00 am that I was given pain medication, almost 4 hours after I complained. Sometimes the pain caused by the ulcer was linked to the pain caused by a surgery that was recently performed. I also suffer from pain from not being able to evacuate. In the end I decided to call my wife who was sleeping at home so she could help me. So she came to the facility at about 4:30 am and helped me clean up, change my position and fix my bed. The nurses did not come. The patient in the bed and his wife witnessed how much I called to the nursing station and all my episodes of vomiting. We waited for the shift supervisor to arrive in the morning and we complained to her. After she intervened the nurses treated us better. According to telephone interview with the wife of Resident #6 on 5/31/17 at 9:30 am, she stated: That day when the situation occurred, it seems that the nurses did not have much staff or they had their situations. My husband called me crying about 4:00 am, and he said he was being mistreated. Immediately I got dressed and went to the facility. I got there at about 4:30 am, I found my husband lying in bed with disorganized bed sheets, without pillow, with vomit, and pain. He told me that the nurses had mistreated him. He told me that at 1:35 am he called the nurses to help him because he was in pain and he was vomiting. When the nurses arrived to the room they helped him but they were very rough in providing the care to my husband. The two nurses told him inappropriate comments. One of the nurses said: I have many patients, do not bother anymore and the other nurse said: You just came here for physical therapies, and nothing else. My husband is an elderly person and has recently had an open heart surgery and that still causes him pain. He also suffered from a stroke during the surgery. I decided to help my husband myself and not disturb the nurses, but as soon as the supervisor came to the unit I went and filled the complaint form. After that day they continued to attend my husband and there was no further problems. The wife of the resident next to my husband heard everything. She testified in the complaint investigation of the facility. The most annoying thing to my husband was the rough treatment and the inappropriate comments of the nurses in charge of him. 4. The facility's grievance and complaint registry was reviewed on 5/24/17 at 10:30 am, the following was found: a. There was found evidence that two residents (resident #6 and #7) filed a grievance report on 4/6/17. b. During review of the Facility's complaint investigation for resident #6 complaint was found the following: i. The resident's #6 wife referred: The resident called at 1:35 am the nurse, employee #11 comes to the resident's room and he asked her to change his position, as per physician's orders [REDACTED]. She did the change but in a rude attitude and nurse said to my husband I will not come back until 4:00 am. Resident called back before that time because was in pain. The nurse delay; he had so much pain that he vomited. At 4:30 am I entered to the room and found my husband on the bed without linen and without pillow. Also, my husband alleges that one of the nurses told him you came here for therapy, not for anything else. c. During review of the Facility's complaint investigation for resident #7 complaint was found the following allegations: i. The resident reported what had happened to her tearfully. ii. During the night resident #7 called the nursing staff on multiple occasions for assistance with the bedpan. iii. The resident #7 referred that in one occasion urine was spilled to the bed and the nursing staff, the RN (Employee #1) and LPN (Employee #2) cleaned and changed the bed sheets. However they performed the care in a rough manner that was uncomfortable to the resident #7. iv. The resident #7 referred that on the last time that the LPN (Employee #2) assisted her with the bedpan the LPN (Employee #7) told her: I am going to train you so you can use the bedpan by yourself because you are calling too much. v. The resident asked to the LPN (Employee #7) for another sheet, however she never received it. vi. The resident informed that nursing staff left the bedpan under the patient and the she had to remove it by herself and she put it on the eating table beside the tooth brush that had been for oral care. She states that the nursing staff did not cleaned the area. vii. The resident #7 referred that one of the nurses (Employee #1 and #2) talked to her in a loud tone and with courage. d. During review of the facility complaint investigation interviews was found that resident #9 was in the same room as resident #7, and he referred: all that my roommate said is true. My roommate was educated and cooperative, but the nursing staff talked to her like they were mad with her and in a loud voice. One of them told to my roommate that she was going to train her to use the bedpan on her own. e. During review of the nursing staff roster was found evidence that from 4/6/17 thru 5/25/17 the RN (Employee #1) and the LPN (Employee #2) were working in the same unit that the resident #6 and #7. The facility maintained the resident #6 and #7 at risk of service interruption, restrictions and other forms of retaliation. Also, all other residents were exposed to abuse and neglect (census: 11 residents). 5. During review of the two facilities complaint investigation that started on 4/6/17 and was completed on 4/18/17 was found evidence that the facility's conclusions were the following: a. They found that the nursing staff (Employee #1 and #2) did not perform the correct nursing interventions with residents #6 and #7. b. They found that the nursing staff (Employee #1 and #2) had bad attitude and behavior towards the resident #6 and #7. c. The facility proceeded to send letters to inform the resident #6 and #7, and the nursing staff (Employee #1 and #2) related to the event of the facility's resolution of the investigation. d. The facility provided re-education to the LPN (Employee #2) related to Abuse and Neglect policy on 5/16/17 because she had previous involvements on related events; however the RN (Employee #1) was not re-educated. According to interview with the Quality and Risk Management Director (employee #6) on 5/24/17 at 10:30 am, she stated: The manner in which complaints and complaints are investigated in the facility is that as soon as we receive the report is send to the unit where the situation related to the complaint occurs. The unit's director and staff are responsible for conducting the interviews and then the interviews are evaluated by the hospital's grievance evaluation committee. The skilled nursing facility does not have its own committee for investigating complaints and grievances. After the committee evaluates the interviews, it sends its recommendations and the skilled nursing facility performs them. The abuse and neglect course was offered this year to all staff. According to interview with the Director of Nursing (employee #14) on 5/25/17 at 9:33 am, she stated: I have knowledge of both of the complaints. The practical nurse was reoriented about out abuse and neglect policy. The registered nurse received a warning. We do not have the habit of removing our staff from the unit during the period of an investigation. According to interview with the Administrative Supervisor (employee #3) on 5/25/17 at 2:00 pm, she stated: The two complaints were investigated at the same time, because they happened the same night. Nurses were interviewed because they had not performed the correct nursing interventions in the management of both patients. One of the patients was presenting clinical changes that required skilled nursing management and coordination with the doctor. One of the nurses denied that the patient was vomiting during that night; however I went to the room and noticed that there was a bag for vomiting that was given to the patient by the nurses. As part of the process after I formally receive the patient's complaint I interview the staff of the unit and those affected. I then deliver the interviews and evidence to the hospital's grievance evaluation committee so they can evaluate it and give the suggestions to follow. According to interview with the physician (employee #15) on 5/25/17 at 2:30 pm, he stated: That patient I remember very well, came without being able to walk to the unit. I have no complaints from him, although I am aware that the resident complained to the nursing staff. My intervention in the care of the residents is clinical, the part of complaints and quarrels are handled administratively. But I understand that while investigating an employee of the facility for abuse and neglect should be removed as the administration understands the unit. This would be the right way to protect and prevent all residents including the complainer. So that person will have no contact with the staff of the facility. I know there is a complaint investigation committee in the hospital but I do not belong to it. 6. During the facility Abuse and Neglect policies and procedures (P&P's) on 5/24/17 at 11:10 am was found that the facility failed to have a mechanism that protects and prevents from abuse and neglect the resident a filled a grievance and all other residents during the investigation processes. A Statement of Deficiency was provided to the facility on [DATE] at 4:25 pm notifying the IJ and requesting a Plan of Correction (P[NAME]). The facility provided a P[NAME] on 5/25/17 at 6:00 pm as follow: General instruction and corrective Actions: 1. The policy and procedure will be amended to include safety measures to prevent exposure of abuse and neglect to other residents meanwhile the investigation process is completed 2. The personnel involve in the allegation will be remove immediately from the skilled nursing facility until the allegation is fully investigated 3. As immediate corrective action the two (2) nurses were remove from the facility 4. The policy will be amended to shorten the time of the investigation when abuse or neglect allegation are suspected The P[NAME] was accepted by the surveyors on 5/25/2017 at 6:05 pm. A mechanism establish by the facility to ensure and protect the residents and to be used with the staff being investigated. During the abuse and neglect investigation process, the Abuse and Neglect Detection and Prevention program was reviewed on 5/24/17 at 11:10 am and it was found that the program, standard and procedure during an employee's investigation that is being investigated for abuse or negligence does not indicate what action to take with the employee during the investigation. No action was provide to protect the resident and / or other residents admitted during the investigation. It was also found during the review of the policies that do not have an independent committee from the hospital to carry out investigations of the cases that occur in the Skilled nursing home. Interview with) 5/24/17 at 9:30 am state I did not participate in the investigations of the complaints; Director of Nursing (employee #14 that is done by the Department of Legal Affairs of the hospital. Interview with the Administrative supervisor (employee #3) performed on 5/24/17 at 1:00 pm she cite: I do part of the investigation, I present it to the committee of complaints from the hospital and I only hear the decision that they take. I do not take decisions in that committee. This committee attends to all complaints from both the hospital and the Skilled Nursing |
2020-09-01 |