| 3544 |
JOHNS ISLAND POST ACUTE |
425368 |
3647 MAYBANK HIGHWAY |
JOHNS ISLAND |
SC |
29455 |
2019-05-20 |
610 |
D |
1 |
1 |
WQ8711 |
**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 investigation, it was determined the facility failed to ensure all allegations of neglect and resident to resident abuse were thoroughly investigated for two of 11 sampled residents reviewed for Facility Reported Incident's (FRI's) (Resident (R) 99 and R43). On 01/22/19 the facility initiated an investigation for an allegation of neglect related to R99, which concluded on 01/25/19; however, when reviewing the investigation, the facility failed to ensure all components of the complaint were investigated. Additionally, during an investigation related to resident to resident abuse involving R43, the facility failed to interview a cognitively intact resident who witnessed the incident. Findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised (MONTH) (YEAR), revealed, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Continued review of the policy revealed. the individual conducting the investigation will, as a minimum: .d. interview any witnesses to the incident; .g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. 1. Review of R99's, Face Sheet, located in the front of the resident's paper chart, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Initial 24-hour Report, dated 01/22/19, provided by the facility's Administrator, revealed the type of reportable incident was alleged abuse. Continued review of the report revealed the RR (resident representative) made allegation of neglect. Investigation initiated immediately. Full report to follow in 5 days. Policy/Ombudsman/MD/RR notified. Further review revealed the date and time of the reportable incident was 01/22/19 at 3:00 PM. Review of the facility's Five-Day Follow-Up Report, dated 01/25/19, specifically, Details of Reportable Incident: revealed, Resident's son/daughter believes his/her mother was neglected on 01/12/19 because s/he was wearing the same clothing in the morning that s/he was wearing the night before and thought s/he was up in her wheelchair all night. S/he stated s/he did not report it to anyone until 01/22 during a care plan meeting. Continued review of the report revealed multiple facility staff including Certified Nursing Assistant's (CNAs) and Licensed Nurses were interviewed regarding R99 being up in her wheelchair at the nurses station all night on 01/12/19; however, there was no documented evidence the staff members were questioned regarding if R99 had been changed out of his/her clothing or not. Interview on 05/01/19 at 1:04 PM, with R99's son/daughter revealed on 01/15/19 it had been reported to him/her by two different CNAs that on 01/12/19, her father/mother was left in her wheelchair all night long and s/he was not changed out of his/her clothes. Continued interview revealed s/he reported this to the former Unit Manager on 01/16/19 via telephone and again on 01/22/19 during his/her parent's care plan meeting. Interview, on 05/02/19 at 5:47 PM, with the Administrator, revealed s/he initiated and completed the investigation. Continued interview revealed when s/he was looking at the allegation of neglect, s/he was seeing the neglect was that the resident was left in his/her wheelchair and not that s/he was not changed out of his/her clothes. This deficiency was cited based on complaint #SC 295. 2. Review of R93's Face Sheet, located in his/her paper chart, documented s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Five Day Follow-Up Report provided by the facility Administrator, documented that on 12/12/18 at 6:59 PM, while R93 was engaged in a verbal argument with R60 (while resident was sitting at a table), R43 approached and tried to intervene. The report documented R93 then struck R43 in the face. The report, which the Administrator identified as the completed investigation of the event, did not include a witness statement from R60. On 5/2/19 at 2:43 PM, the Administrator stated s/he was responsible for coordinating the investigations into incidents, including resident to resident altercations. The Administrator stated a thorough investigation should include statements from all witnesses, and s/he would usually interview any resident with a BIMS of a 6 or greater. The Administrator stated s/he could not explain why s/he did not interview R60 as part of his/her investigation into the incident. This deficiency was cited based on complaint #SC 886. |
2020-09-01 |