| 10293 |
L.M.C.- EXTENDED CARE |
425321 |
815 OLD CHEROKEE ROAD |
LEXINGTON |
SC |
29072 |
2010-09-30 |
225 |
D |
|
|
IK8X11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09, the facility failed to report to the state agency and investigate the alleged verbal abuse of Resident #13, one of 18 residents reviewed for abuse and neglect; the facility failed to complete an incident report related to a skin tear on Resident #30. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an individual interview on 9/29/10 at 11:05 AM, Resident #13 stated that she was lying on her side when a Certified Nursing Assistant (CNA) laughed and made an unprofessional/inappropriate remark related to the resident's size.. Resident #13 stated the CNA pushed her so hard she almost pushed her out of the bed. The resident stated that it had not been long since the incident occurred. She stated she had asked that the CNA not be allowed to take care of her and stated that the CNA had been taken off the floor. During an interview on 9/29/10, the Assistant Director of Nursing (ADON) stated she was unaware of the incident and it had not been reported to her. During an interview on 9/30/10 at approximately 11:00 AM, Nurse A stated she was aware of the incident, but hadn't been on duty at the time the incident occurred. Nurse A stated she had reported the incident to her supervisor, RN #2. Nurse A stated the CNA involved in the incident had requested to be moved off the floor, and had not been moved as a result of any disciplinary action. During an interview on 9/30/10 at approximately 11:30 AM, RN #2 denied any knowledge of the incident and stated that the nurse must have reported the incident to another nursing supervisor. During an interview on 9/30/10 at 12:00 Noon, the Director of Nursing (DON) stated she was unaware of the incident. After reviewing the CNA's personnel record, the DON verified the CNA had been transferred to another unit at the CNA's request. The DON agreed that the incident would need to be investigated had it been reported. Review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09 revealed under "5. Investigation, A. All suspicious incidents will be thoroughly investigated in a timely fashion, documented via an Alleged Abuse/Incident of Unknown Origin packet, and forwarded to the required state agencies as outlined in policy 02-22, Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Responsibilities". The Policy/Procedure section stated that "DHEC Certification and the facility administrator shall be notified immediately but not to exceed 24 hours after discovery of all alleged violations involving abuse (physical, verbal, sexual, or mental)...". Under Abuse Reporting Procedure the "1. Nurse or Shift Supervisor: a) Receives the complaint from a resident..., b) Assesses the complaint and interviews the complainant, c) Obtains a written statement form included in packet, d) Obtains written statement notarized or signed by two witnesses, e) Contacts shift supervisor, f) Completes incident report." From there, the packet goes to the "2. Shift Supervisor...3. Assistant Director of Nursing or Nurse Supervisor...," and then to "4. Administration". Interview on 9/29/10 with the Assistant Director of Nursing, who performs investigations of abuse, indicated that s/he was not aware of the alleged verbal abuse. The facility admitted Resident #30 on 05/28/2010 with [DIAGNOSES REDACTED]. Resident #30 sampled as a result of a complaint concerning skin tears. Review of Resident #30's closed medical record on 09/27/2010 revealed nursing documentation on 06/07/2010 and 07/21/2010 regarding skin tears. On 06/07/2010 a nurse's note stated, "...F/U (follow-up) to skintear..." Review of the Occurrence Reported dated 06/07/2010 indicated that the resident received the skin tear while participating in physical therapy. Continued review of the nurse's notes revealed a 07/21/2010 note at 2000 that stated, "...Res (resident) has ST (skin tear) on (R) (right) elbow..." The facility was unable to provide an Occurrence Report for the 07/21/2010 skin tear. Review of the skin integrity care plan dated 06/16/2010 did not address the skin tears. |
2014-01-01 |