cms_SC: 2196
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2196 | ROLLING GREEN VILLAGE | 425160 | 1 HOKE SMITH BOULEVARD | GREENVILLE | SC | 29615 | 2019-11-14 | 610 | D | 1 | 0 | NVCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation for one (1) resident who made an allegation of sexual abuse (Resident #1). The findings included: Review of the facility's undated Abuse Policy: documented the following: Protection Abuse Policy .The progress notes, concerning all residents involved, should include: 6. What was done to prevent further harm to resident or others. Documentation will continue over 72 hours. An acute care plan will be developed that identifies methods for prevention of further occurrence .In House Investigation .Steps taken to protect the alleged victim from further abuse, particularly when an alleged perpetrator has not been identified. Actions taken as a result of the investigation, to include corrective action taken .Abuse Prevention Program, Community Procedures VI. 4. Investigation procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents .7. Final Abuse Investigation Report .The final investigation report shall contain the following .Facts determined during the process of the investigation, review of medical record and interview of witnesses . Conclusion of the investigation based on known facts .Attach a summary of all interviews conducted .VIII. External Reporting of Potential Abuse. 1 .Steps the community has taken to protect the resident. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating moderate cognitive impairment. The MDS recorded the resident had minimal hearing difficulty, clear speech, made herself understood, and understood others with clear comprehension. The MDS recorded the resident had no signs or symptoms of [MEDICAL CONDITIONS], hallucinations or delusions, and had rejected care one (1) to three (3) days during the assessment period of seven (7) days. The MDS further recorded the resident required extensive assistance of one (1) staff for toileting and personal hygiene, and the resident had occasional urinary incontinence. The resident was documented as receiving antidepressants seven (7) days during the assessment period. Review of Resident #1's care plan dated 6/26/19 for occasional urinary incontinence directed staff: Check for incontinence; change if wet/soiled. Clean skin with mild soap and water, apply moisture barrier, keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bed quickly, remind to empty bladder before meals, at bedtime, and before activities. Review of the Clinical Notes from 6/30/19 through 8/1/19 written by Nursing and Social Services (SS) recorded several instances of behaviors by the resident including confusion, disorientation, refusals of care, accusations toward staff, and hallucinations. Dates for the behavior notes in the record were 6/30/19, 7/1/19, 7/6/19, 7/8/19, 7/9/19 (two notes), 7/16/19, and 7/24/19. Staff did not document any additional behaviors in the medical record. On 7/24/19, the Social Worker (SW) documented, SW place (sic) in psychiatrist book to be seen for increase (sic) hallucinations. Review of the Psychiatrist and Psychiatric Nurse Practitioner (NP) notes from 7/10/19 through 8/20/19 recorded the resident was frustrated, irritable, disoriented at times, had cognitive impairment, and expressed having hallucinations. The Psychiatric notes were dated 7/10/19, 7/16/19, 7/23/19, 7/31/19, 8/7/19, and 8/20/19. Review of the initial abuse allegation report dated 8/1/19 revealed the resident's family member reported to the Executive Director that the resident told her on a couple of occasions a staff member came to her room at night and put their finger in her vagina. The facility documented, Investigation initiate (sic). No staff member identified at this time, however the Charge Nurse for 2nd shift and 3rd shift aware and will monitor staff and resident interactions during the investigation and will notify ED/DON (Executive Director/Director of Nursing) of any questionable interactions. Review of the final abuse investigation report dated 8/6/19 recorded, no witnesses, no description of perpetrator, no date given, happened during the night, and list of 3rd shift employees. Interventions by facility to prevent future Injury/Alleged Abuse: Res (resident) to be 'checked' for incont (incontinence) last on 2nd shift, only visual checks when asleep and 1st check on 1st shift. Limit waking up the res (resident) to provide care as long as res (resident) remain (sic) safe and clean. The abuse investigation did not contain any witness statements or written statements by staff, and the facility did not interview any other residents to determine the potential scope of the alleged sexual abuse. The abuse investigation did not consider an increase in the resident's negative behaviors and hallucinations as a potential expression of actual sexual abuse. During interview on 11/14/19 at 10:20 AM, the DON presented a narrative she wrote on 11/14/19 of what transpired on the night shift, the day the allegation was made, 8/1/19. This narrative was not part of the actual sexual abuse investigation. The DON stated Licensed Practical Nurse (LPN) #A was the night time supervisor and the DON asked her to interview the three (3) Certified Nursing Assistants (CNAs) who worked the night shift on 8/1/19. The DON stated that the LPN reported the CNAs were, Turning on the lights, pulling back the covers, doing visual checks of the resident's brief, and it was apparent how the resident could have felt concerned about it; they were waking her up to check her, and she is a very sound sleeper. The DON continued, We did not do any other resident interviews on the unit. We thought it was an isolated event. We did not hear anything from other residents about night time staffing or care concerns, but no we didn't directly ask them (the residents). We did not get individual statements from staff. Statements weren't put on paper, but they occurred on the 3rd shift, with the 3 CNAs, the communication was done, and put in a summary, not individually. The residents on that unit, care issues/concerns are discussed at each care plan meeting. The Social Worker (SW) asks how the care is and how the staff is treating them. We ask the families and the resident. During interview on 11/14/19 at 2:38 PM, LPN #A stated she received an email from the DON who asked LPN #A to do a body audit on the resident and talk to the CNAs on 3rd shift. Then she reported back to the DON. LPN #A stated she asked the CNAs how they toilet and check the resident's brief. LPN #A further stated she did not get any written statements from the three (3) CNAs, she met with them and they talked about care, and she did not interview any other residents. LPN #A determined the resident was a heavy sleeper and misunderstood the staff was providing incontinent care, not sexually abusing her. After discussing it with the DON, they decided to change the way the staff checked and changed the resident, to the last check on the evening shift and the first check on the day shift. LPN #A also stated, The whole investigation process was done in one (1) day. I really did think it was a behavior (the sexual abuse allegation) from transitioning from home to LTC (Long Term Care). The (family member) stopped coming as much so that the resident could adjust and make friends, and I think (the resident) was trying to sort of manipulate her (family member) to go back home. I didn't discount what she was saying about the abuse. The reason I say that's what her problem was (versus potentially acting out with behaviors as a result of abuse) rather than actual abuse; I could tell she missed being at home. During interview on 11/14/19 at 3:24 PM, the MDS nurse stated for an acute problem, such as abuse issues, The SW is the first go-to. They write up the initial report usually. They primarily do the interviews. They would update the care plan. During interview on 11/14/19 at 4:05 PM, SW #1 stated she was informed about Resident #1's sexual abuse allegation, and staff was going in to check if she was incontinent and they put their finger down her brief. SW #1 stated the discussion was about that the resident would be the last check on 2nd shift about 11:00 - 11:30 PM and 3rd shift would not check her, and then she would be the first person on the 1st shift to be checked. SW #1 stated staff did the investigation by interviewing the resident, but did not interview anyone else, I wrote up the initial concern form and gave it to the DON. At 4:45 PM, the SW stated she did not take any actions to protect the resident during the investigation. During interview on 11/14/19 at 4:28 PM, CNA #1 stated she worked both evening and night shifts and provided care for Resident #1 on the night shift and checked the resident every two (2) hours. CNA #1 stated. I pull the covers back to check her brief and look for the line (line on the brief turns blue when wet). I wake her up, she wakes up when you go in unless she's in a deep sleep, she doesn't sleep deeply. Nobody ever interviewed me about (the resident) for anything about sexual abuse. Nobody told me or trained me about any new care interventions or procedures since then. During a follow-up interview on 11/14/19 at 4:47 PM, the DON stated the facility did not protect the resident during the investigation because, It was a quick investigation. We had the family involvement and the staff knew exactly what could have happened. The DON stated they, Should have checked to see if it was unit wide. The DON stated the abuse policy does state the resident should be protected during the investigation, But we didn't feel that there was anyone who was harming her. The DON stated typically they do take into consideration that an increase in behaviors could be a response to sexual abuse, but in this case they didn't because, We felt we knew what happened. During interview on 11/14/19 at 5:17 PM, the Executive Director (ED) stated staff usually looks at the pieces for what is causing behaviors and talk to the physician. I feel that we did a thorough investigation, and We act on the information we think is truthful, and I think we did a thorough investigation .looking back, we should have had other things documented. It may have been a nurse's rush to judgement, but she's a good judge of what has occurred because she knows the resident. | 2020-09-01 |