cms_SC: 2198
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2198 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 607 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policy by failing to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner, failed to place potential perpetrators on leave during investigations, failed to ensure residents were interviewed during the course of the investigations, and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 resident's residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 01/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated, They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to resident incident report that occurred on 01/14/19. Review of the facility's investigation record revealed the investigation into Resident #5's allegation of abuse was not initiated until 01/31/19 after the resident reported the allegation directly to the Administrator. Interviews of additional residents related to staff treatment could not be found in the investigation record. Staff interviews were conducted during the facility investigation, and revealed Certified Nurse Aides (CNA) #2 CNA #16, Licensed Practical Nurse (LPN) #6, and the Social Services Director (SSD) were aware of Resident #5's allegation of being sodomized on 01/14/19 (16 days prior to the allegation being reported by the resident to the Administrator). No evidence could be found in the facility's investigation file to indicate the allegation had been reported, by these staff members, to administration. Review of LPN #6's statement, dated 01/31/19, indicated the resident stated, Get your finger out of my ass! The statement indicated Resident accused CNA of sodomizing (him/her). Review of CNA#16's statement, undated, indicated the resident was yelling, Help .I've been raped and sodomized. Review of a Grievance Form, completed by the SSD on 01/14/19, indicated the resident reported s/he was sodomized on 01/14/19. During the course of the investigation, multiple staff members, including CNA #2, CNA #17, CNA #16, LPN #6, the SSD, and the Administrator were accused of sodomizing Resident #5. Review of the facility's investigation revealed staff members identified in the allegation of abuse were not put on administrative leave during the course of the investigation. Further, the investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. Review of Resident #3's EMR Admission Record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS assessment with an ARD of 09/22/19, revealed the resident had both short and long-term memory problems and required extensive assistance from staff to complete all ADLs. A request was made on 01/16/20 at 1:00 PM to the Administrator for the staff to resident investigation that involved Resident #3 and CNA #10 on [DATE]. Resident #3's family member alleged CNA #10 was rough with the resident during care on [DATE]. The facility's investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. Review of Resident #18's EMR Admission Record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #18's (Re) Admission MDS assessment with an ARD of 12/31/19, specified the resident had both short and long-term memory problems and required extensive assistance from staff to complete all of his/her ADLs. A request was made on 01/16/20 at 1:00 PM to the Administrator for the staff to resident investigation that involved Resident #18 and CNA #9 on 12/25/19. Resident #18's family member alleged that on 12/25/19, CNA #9 was mean and aggressive with the resident during care. The facility's investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. During interview on 01/17/20 at 3:30 PM, the Administrator/Facility Abuse Coordinator stated, allegations of abuse are to be reported immediately and all alleged perpetrators should be immediately put on administrative leave during the course of an investigation. All allegations are to be reported to the local ombudsman within the required timeframe, and all parties who might have knowledge about a reported allegation should be interviewed as part of the investigation. This includes any interviewable residents potentially affected by the allegation. Review of the facility's policy titled, Elder Abuse, revised 09/04/19, indicated, . An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation occur, the facility will,.Provide residents, representatives, and staff information on how and whom they may report concerns, incidents, and grievances without the fear of retribution.Written procedures for investigations include: Identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, .Alleged violations will be reported to the Administrator, state agency, adult protective services, and all other required agencies immediately, but no later than 2 hours after the allegation is made. | 2020-09-01 |