| 3315 |
MARTHA FRANKS BAPTIST RETIREMENT CENTER |
425334 |
ONE MARTHA FRANKS DRIVE |
LAURENS |
SC |
29360 |
2018-02-14 |
610 |
G |
1 |
0 |
QB4N11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to prevent further potential abuse and neglect while investigations were in progress and when an alleged violation was verified failed to take appropriate corrective action. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. She asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations. |
2020-09-01 |