| 6246 |
BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER, |
425004 |
101 COTTAGE CREEK CIRCLE |
GREER |
SC |
29650 |
2014-09-04 |
226 |
D |
0 |
1 |
0BDJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime, and interview, the facility failed to implement their abuse policy by not reporting an alleged abuse timely and developing a plan of action to protect Resident #7 from potential harm. 1 of 3 reportable's reviewed for alleged abuse. The findings included: The facility admitted Resident #7 with a [DIAGNOSES REDACTED]. On 09/03/14 at approximately 10:50 AM a review of the 07/07/14 Quarterly Minimum Data Set (MDS) revealed the resident had a Basic Individual Mental Status (BIMS) score of 3, indicating that the resident was severely cognitively impaired. On 09/03/14 at approximately 11:00 AM a review of an investigative report sent to the State Agency by the facility on 06/16/14 revealed three separate occurrences of a visitor allegedly having inappropriate interactions with Resident #7. The first incident reported by Licensed Practical Nurse (LPN) #1 occurred on 06/12/14 stated a visitor had exhibited inappropriate behaviors toward Resident #7, including fondling of the breast and kissing the resident. LPN #1 stated s/he had observed the visitor on two separate occasions (06/12/14 and 06/14/14) in the common area of Dogwood Cottage giving a peck kiss to Resident #7 on the mouth and brushing up against resident's breast with part of his/her hand and arm while hugging resident. LPN #1 stated that on 06/13/14, visitor and wife were sitting to the left side of the common area and Resident #7 was sitting on the right side of the common area. The visitor got up from a chair and wheeled Resident #7 over to where the visitor and wife was sitting. The visitor placed Resident #7 on the right and sat in the middle. The Certified Nursing Assistant (CNA) removed Resident #7 away from the visitor. The investigative report also revealed that LPN #1 had reported the incident to Social Worker #1 and the Nursing Supervisor on 06/12/14. LPN #1 reported the 06/13/14 incident to the Nursing Supervisor and the second shift nurse. Immediately following the initial occurrence, nursing had instructed the staff to ensure that Resident #7 was not within close proximity when the visitor was present. The report revealed that notification of the Social Worker Supervisor did not occur until 06/16/14. Following the notification of the Social Worker Supervisor 06/16/14, a plan was put in place to supervise the visitor and an investigation was initiated. The Police Department was notified and began an investigation. Review of the Nurses Notes dated 06/12/14 at 2:51 PM revealed documentation that stated the social worker was notified of a visitor fondling Resident #7's breasts and kissing her. Nurses Notes dated 06/15/14 at 3:38 PM revealed a late entry by Licensed Practical Nurse (LPN) #1 for 06/14/14 stating: this nurse had placed this elder to the right of the common area. #3 (the visitor) was sitting on left of the common area literally got up from his chair and placed this elder next to him and wife. Nurse came out of the room and removed elder from that space. No further episodes this shift. Nurses Notes written by LPN #1 dated 06/15/14 at 3:43 PM revealed the visitor was sitting to left of the common area. Resident #7 was sitting closer to the fireplace. When this nurse came out of room [ROOM NUMBER], the visitor was hugging the resident and had his right arm across chest fondling elders right breast. Social worker was aware of behavior. Interview with LPN #1 on 09/03/14 at approximately 11:40 AM revealed a different occurrence of the three incidents of alleged abuse by the visitor and Resident #7. LPN #1 stated in the interview that jiggling/ fondling of Resident #7's breast incident 06/12/14 by the visitor might have been the wrong words to use. LPN #1 stated what s/he and the CNA actually saw was the visitor on the right side of Resident #7's wheelchair, had left hand on chair and moved right hand across resident's upper abdomen, gave tight hug and a short peck kiss on the lips. S/he informed the visitor it was inappropriate. There were no other episodes and s/he notified Social Worker #1 and the Nursing Supervisor after the incident. S/he then alerted the staff to watch and keep resident away from the visitor. The second incident on 06/13/14, the visitor moved Resident #7 closer to him/her wife. The CNA intervened and took Resident #7 to the bathroom. The third incident 06/14/14, the visitor got up from the chair, went over to Resident #7, leaned down and touched the resident's arm. The visitor got up and moved to the dining table after seeing LPN #1. During the interview, the surveyor asked LPN #1 had Resident #7's behavior/demeanor changed since the incidents. LPN #1 stated resident's demeanor/behavior did not change and has not changed. On 09/03/14 at approximately 2:20 PM during an interview with SW #1 and s/he verified that LPN #1 did report the incident of 06/12/14 and stated one had observed the visitor on 06/12/14 and 06/13/14 and did not see any inappropriate interaction between the visitor and Resident #7. An interview with CNA # was conducted on 09/03/14 at approximately 3:30 PM. The CNA verified what s/he and LPN #1 actually saw on 06/12/14 and 06/13/14. On 09/03/14 at approximately 4:25 PM, the surveyor that conducted the group meeting had asked 21 residents, from various cottages, including Dogwood Cottage, regarding if they had concerns or saw any abuse or inappropriate actions by visitors, other residents or staff. The surveyor stated all 21 residents had no concerns. Based on review of facility's report, record review, and interviews, the alleged abuse could not be substantiated. The Nursing Supervisor at time of the investigation was not available for interview at the time of the survey. Review of the facility's policy entitled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime on 09/03/14 at approximately 1:30 PM revealed that all alleged violations were to be reported to the State Regional Ombudsman, Department of Health and Environmental Control (DHEC) Division of Certification, and DHEC Division of Health Licensing within 24 HRS of the reported allegation of abuse. The policy also revealed in Section 3f regarding Protection of the Resident that the facility procedures included, but were not limited to, removing staff, visitors, volunteers, family members, and others that have abused a resident of the facility until the matter is investigated and resolved. Interview with the Administrator of the facility at the time incident occurred on, 09/04/14 at approximately 10:15 AM, confirmed the incident occurred on 06/12/14 and should have been reported to management and the appropriate State Agency. The Administrator also stated interventions to protect the resident, as per policy, should have been implemented immediately. |
2018-04-01 |