cms_SC: 52
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 52 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 610 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, the facility failed to thoroughly investigate and prevent the possibility of further neglect from occurring for 1 of 24 sampled residents (Resident #17). On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 failed to ensure the resident was safe from falling and as a result, Resident #17 fell and sustained lacerations to the left eyebrow and left upper cheek. According to the facility's Investigation Report, only CNA #6 and the assessing Registered Nurse (RN) #2 were interviewed regarding the incident. In addition, CNA #6 was not suspended pending the outcome of the investigation. The findings included: Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. All reports of possible abuse are promptly and thoroughly investigated by facility management. Residents and staff are protected during incident investigation by ensuring reports are made without fear of retaliation and that anonymous reports are investigated. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence .Completion of the following interviews: i. Person(s) reporting the incident; ii. Any witnesses to the incident (a) The resident (if appropriate); (b) The resident's roommate, family members and visitors (if applicable); (c) Staff members who have had contact with the resident during the period of the alleged incident. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. In addition, there were no other witness statements documented in the Investigation Report. Review of CNA #6's Employee file revealed the aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence in reference to failing to follow proper turn and reposition technique. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. Interview at this time with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor. CNA #6 told CNA #1 that she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. CNA #1 was not sure if CNA #6 was suspended during the investigation of the incident. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. According to the DON, a thorough investigation included interviewing the resident involved in the allegation (if possible), other residents, all pertinent staff/family/visitors (as applicable). When reviewing the witness statements from CNA #6 and RN #2, the DON confirmed that components of their statements were contradictory. The DON said when contradictory statements were obtained during an investigation, it was expected for the assigned Investigator to conduct follow-up interviews to obtain clarification. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. The ADON said that all witness statements (2) were included in the Investigation Report. In addition, the ADON said the resident's fall was not identified as a possible incident of neglect and CNA #6 was written up because she performed peri-care incorrectly. Continued interview with the ADON confirmed that the aide's failure to properly perform peri-care could be possible neglect that required investigation. Further interview revealed that CNA #6 was not suspended pending the outcome of the facility's investigation. | 2020-09-01 |