| 2 |
BRUSHY CREEK POST ACUTE |
425004 |
101 COTTAGE CREEK CIRCLE |
GREER |
SC |
29650 |
2019-01-21 |
610 |
E |
1 |
0 |
ZBYG11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to ensure all allegations of abuse and injury of unknown sources were thoroughly investigated for four of 14 sampled residents reviewed for facility reported incidents (FRI's) (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to interview other residents of the facility. On 12/02/18 a sewing needle was discovered in R4's wound on top of her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to initiate an investigation. On 01/08/19 R1, who was not cognitively intact, experienced what the facility identified as an injury of unknown source; however, it was not thoroughly investigated. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to conduct a thorough investigation. Findings include: Review of R9's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS) completed on 11/05/18 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM. Review of the facility's Five-Day Follow-Up Report, dated 11/5/18, revealed Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 1 were the only staff interviewed about the incident. Additionally, there was no documented evidence interviewable residents in the facility were interviewed. During an interview on 01/20/19 at 6:10 PM, the facility's Risk Manager (RM) revealed s/he was responsible for reporting all reportable incidents to the state agency and investigating the reportable incidents. Continued interview with the RM revealed s/he did not interview any interviewable residents in the facility that had received services from RN2. During an interview on 01/21/19 at 9:50 AM, the Director of Nursing (DON) revealed s/he assisted the RM in completing the investigation of alleged abuse against R9. The DON revealed that s/he believed, based on RN2's typed witness statement, RN2's verbal explanation, and the two staff members' witness statements, that was all that was needed to unsubstantiated the allegation. Review of R4's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18 revealed the facility assessed the resident to have a BIMS score of four out of 15, indicating the resident was severely cognitively impaired. Review of the facility's reportable incidents revealed no documented evidence the sewing needle being discovered in R4's wounds was identified as an injury of unknown source to be investigated. A subsequent interview on 01/20/19 at 2:35 PM with the facility's Risk Manager (RM), the RM revealed, even though the resident's cognitive status prevented the resident from explaining how the needle got into the wound and it was not witnessed, the facility did not identify the incident as an injury of unknown source. During an interview on 01/21/19 at 8:38 AM, the Administrator revealed s/he did not participate in the investigation related to the allegation of verbal abuse to R9. The Administrator revealed when the survey team showed her/him the witness statements, it was the first-time s/he had seen the statements. The Administrator revealed s/he did not remember the allegation being reported to her/him by the RM and s/he did not have any documented evidence it was reported to her/him. The Administrator stated s/he can see how R4's injury could have been identified and investigated as an injury of unknown source. During an interview on 01/21/19 at 3:10 PM, Licensed Practical Nurse (LPN) 2 revealed s/he was the one who discovered a sewing needle in R4's wound on top of her/his right foot. Continued interview revealed after pulling the sewing needle out, s/he notified her/his supervisor per policy. LPN2 revealed, to her/his knowledge, there was no investigation completed. Review of LPN2's nursing notes, dated 12/02/18, revealed while doing wound care on the top of R4's right foot where the resident had an ulcerated lesion, the gauze got caught on what was thought to be a scab; the gauze got caught on a sewing needle that was sticking out of the wound. The nursing notes revealed the nurse pulled the sewing needled out of the wound and then notified her/his supervisor and the resident's daughter. Review of the undated policy Abuse Investigation and Reporting revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . the role of the investigator at a minimum would interview any witnesses to the incident, interview the resident's roommate, family members and visitors, and consult daily with the administrator. Review of R1's Face Sheet in the clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's quarterly MDS, dated [DATE] indicated that R1 was severely cognitively impaired an unable to answer the questions on the Brief Interview for Memory Status. Review of the Initial 24-hour Report, dated 1/14/19, indicated swelling to R (right) hand with skin tears. The date and time of the reportable incident indicated 1/14/19 at 8:00 PM. Review of the Five-Day Follow-up Report, dated 01/18/19, indicated the same injury as the initial report and the same date and time. The document indicated the category of Details of Reportable Incident the following, Resident noted to have swelling to R hand on 1/14(/19) at approx. 8:00 pm, son notified nursing staff . Staff report resident was restless during the day. Review of the facility's documentation provided by the Administrator indicated that the facility obtained written statements from the nurses and nurse aides on 01/13/19 and 01/14/19. The Assistant Director of Nursing (ADON) confirmed that the night nurse (LPN1) on the night shift, starting at 7 PM on 01/13/19 and ending at 7 AM on 01/14/19, did not write a statement. Review of the statement written by Certified Nurse Aide (CNA) 2 dated 01/18/19 indicated, I worked with (R1) on Monday, (MONTH) 14th in Rose Cottage . I removed her/his hand brace, like usual and gently cleaned just under her/his fingers. S/he had the skin tears and band aids, so I left those on. Review of the statement written by CNA3 dated 01/14/19 indicated, I worked on Sunday evening/night shift . there was no problem with (R1) the night or when I left work on Monday morning at 7 am. When I returned to work on Monday evening around 7:35 pm, her/his son (son's name) was here and asked me if I knew about the scratch and bruise to her/his right hand. Her/his hand was swollen and appeared to be bruised . The CNA did not mention anything about her/him having any problem with her/his hand during the day. Review of R1's Progress Notes, dated 01/10/19 through 01/16/19, revealed that there was no documentation regarding how R1's skin tears occurred or that band aids were placed over the right-hand skin tears. During an interview on 01/21/19 at 1 PM with the Administrator and ADON, the Administrator confirmed that LPN1 did not write a statement and that the facility did not have any further documentation that an investigation had been conducted to determine how the skin tears occurred that were documented in NA2's written statement. The Administrator confirmed that the CNA3 documented on Sunday, 01/13/19, there was no problem with R1's right hand; however, CNA2 documented on the day shift of 01/14/19, R1 had band aids and skin tears to the right hand. Review of R11's medical record revealed Physician Orders, dated 09/10/18, which indicated (narcotic medication) (buprenorphine) Patch Weekly 5 MCG (microgram)/HR apply 5 MCG/hr [MEDICATION NAME] (sic) weekly every Mon (Monday) for pain. Review of an email dated 09/20/18 at 7:18 AM from RN4 indicated, (name of Nurse Practitioner) left a prescription (dated 09/11/18) on the keypad for the (name of brand of narcotic) (buprenorphine) patch. I promptly faxed it and fax confirmation was received. I did not call (Name of Pharmacy) with a follow-up phone call to confirm receipt of the prescription. Review of a hand-written document that was part of the facility's investigation file, dated 09/19/18, indicated on 9/11/17 (sic - the year should have been (YEAR)) I did not receive the (name of brand of narcotic) (buprenorphine) patch for resident (R11) in narcotic bag. The document was signed by RN5. Review of the email from the ADON to the facility's Risk Manager dated Monday, 09/17/18 indicated, I received a call from (LPN 7) . s/he was unable to find the narcotic medication, '(name of brand of narcotic) (buprenorphine) [MEDICATION NAME]es.' The medication was signed as received by RN5 on (MONTH) 11th at 11:07 pm. After searching all subacute cottages for the med (medication) to no avail, I called the pharmacy and asked for a copy of the signature page. The signature page was sent and does appear to have been signed by the said nurse at the said time. I called (RN5) . s/he has no recollection of receiving any narcotic patches. I informed (RN 5) I have a copy of the signature page showing s/he signed for the med (medication). (RN5) again stated, 'If I did sign the paper, I do not remember receiving any narcotic patches.' During an interview on 01/20/18 at 9 AM with the ADON and Administrator, the ADON stated that the pharmacy sent the residents' medication by courier. The courier delivered the medications to each cottage. The narcotics arrived in a pink bag with a pink slip that the nurse had to sign. The ADON stated that the facility did not have the pink slip that someone signed on 09/11/18. The ADON stated that when the nurse received the narcotic there was a narcotic sheet in the bag that the nurse then signed, added the number of pills, and placed the sheet in the cottage's narcotic book. The ADON stated that since the facility did not receive the buprenorphine patches for R11, there would not have been a narcotic sheet in the narcotic book. Therefore, that was why the nurses did not notice after 09/11/18 that the resident did not have the buprenorphine patches in the locked narcotic drawer. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified by the ADON on 09/17/18 that R11's buprenorphine patches were not available at the facility. The RM stated that there was no documentation in the documents provided by the facility that a search of all 12 cottages' locked narcotic boxes in the medication carts was performed to see if the patches were delivered to another cottage. The RM confirmed that the email from the ADON on 09/17/18 indicated that a search of the subacute cottages was performed, but not of all of the cottages. The RM stated there was no documentation that interviews were conducted with the residents who may have been seated near the medication cart or with the nurse aides who were working during the time on 09/11/18 when the courier brought the medications to the cottage. The RM also confirmed that the facility did not interview the courier. The RM stated that the facility turned the investigation over to the pharmacy and have not heard anything further regarding the missing buprenorphine patches. Review of the undated policy Abuse Investigation and Reporting revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . the role of the investigator at a minimum would interview any witnesses to the incident, interview the resident's roommate, family members and visitors, and consult daily with the Administrator. |
2020-09-01 |