cms_RI: 96
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 96 | WEST SHORE HEALTH CENTER | 415028 | 109 WEST SHORE ROAD | WARWICK | RI | 2889 | 2017-10-25 | 225 | D | 1 | 0 | REJ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and staff interviews, it has been determined that the facility failed to ensure that all alleged violations of abuse, including injuries of unknown source, are thoroughly investigated and reported to the state agency for 2 of 10 sample residents (Resident ID#s 1 and 10). Findings are as follows: 1. On 10/23/2017 a community complaint was filed to the State Agency regarding bruising discovered by staff on or about 10/11/2017 on Resident ID#1's pubic bone which the facility told the complainant was caused by a diaper. The complainant revealed that s/he requested an investigation by the facility and discovered that the facility never reported the incident to the State Agency. Review of Resident ID#1's 10/10/2017 11:52 PM progress note written by Staff Nurse B states, in part, During HS (hour of sleep) care CNA (certified nursing assistant) reports ecchymotic (bruise) that was not there when she worked last night. assessed with [REDACTED]. Ecchymotic area noted to from pubis mons (tissue over the pubic bone) to right hip Reported to Director of Nursing Service (DNS) via telephone. Will continue to monitor . Surveyor observation of the resident on 10/23/2017 at 3:15 PM in the presence of Supervisor Nurse C and the Nurse Practitioner revealed only fading right hip bruising and the area over the mons pubis resolved. Surveyor interviews were conducted with multiple facility staff and revealed descriptions of the injury and the following speculations on possible causes of the ecchymosis: -10/23/2017 3:20 PM Supervisor Nurse C revealed it could have been caused by a gait belt (a device used for assisting resident with ambulation). -10/23/2017 3:21 PM Nurse Practitioner revealed that her first observation of the wound was on this date in the presence of the surveyor and that it could possibly have been caused by rolling onto an item, like a bed control, during repositioning in bed. -10/24/2017 7:36 AM Staff Nurse D revealed that Resident ID#1 is sometimes resistive to care and will slam her hands in that area (bruised area) or could be caused by the resident bumping into the corner of furniture, though the resident is not supposed to ambulate independently she does get up on her own. -10/24/2017 10:10 AM Assistant Director of Nursing Service (ADNS) revealed that he was notified on 10/11/2017 of the resident's bruising. Upon his observation on that date the resident was wearing a shirt and a brief. He revealed that that the brief was all bunched up and crooked and that there was linear bruising where the brief was bunched. Additionally, he revealed that he was confident in his findings, that this was not an injury of unknown origin, despite the location or size of the injury and therefore it was not reported. -10/24/2017 at 1:30 PM Staff Nurse B revealed that on 10/10/2017 the resident's primary CNA requested an assessment of the bruise. The large bruise extended from the mons pubis to the right hip in an upside-down swoosh pattern. The injury was reported to the DNS via telephone that night, Staff Nurse B was instructed by the DNS to write a note about the area and an assessment would be done the next day. -10/25/2017 at 11:45 AM CNA Staff [NAME] revealed that on the night of 10/10/2017 she took Resident ID#1's brief down for care and the top of private area was the only affected area by the bruising and the next day the bruising had spread. Staff [NAME] revealed that she reported the bruise right away to the nurse. During a surveyor interview with the resident's guardian and another family member on 10/24/2017 at 12:00 PM they revealed photographs on a cellular phone from 10/11/2017 of Resident ID#1's ecchymotic area which extended from the right hip to approximately 3/4 of the the mons pubis area, dark red and purple in color. In an interview with the Administrator on 10/25/2017 at approximately 10:00 AM she revealed that she was confident that the ADNS investigation was thorough regarding the source of the injury of unknown origin and was not suspicious and therefore did not report the injury to the State Agency despite the surveyor's interviews with other facility staff regarding possible causes of the injury. 2. Upon investigating a facility reported complaint involving Resident ID#2 an additional allegation of resident to resident abuse, related to touching another resident in a sexual/inappropriate manner on 4/26/2017, was discovered by the surveyor. Record review for Resident ID#2 revealed an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. A progress note dated 4/26/2017 at 10:40 AM states, in part, .CNA reported to writer that resident was observed in another .resident's room (Resident ID#10) touching (him/her) in a sexual/inappropriate manner . In an interview with the with the Administrator and the DNS on 10/25/2017 at 1:40 PM they revealed that there was not an internal investigation and that the incident was not reported to the state agency. | 2020-09-01 |