| 8213 |
CHESTER NURSING CENTER |
425061 |
1 MEDICAL PARK DRIVE |
CHESTER |
SC |
29706 |
2012-05-03 |
226 |
L |
0 |
1 |
WII411 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** July 17, 2012 - Ammended to reflect change to original Scope and Severity to K and lowered Scope and Severity to E On the days of the Recertification and Extended survey, based on interviews, record reviews, and review of the facility Abuse and Neglect Policy the facility failed to follow its policies and procedures that prohibit mistreatment, neglect, and abuse of residents. The facility staff failed to report neglect involving Resident #11 who suffered a burn related to a heat treatment which was applied incorrectly. The incident was not investigated and reported to the State Agency. The facility staff failed to respond when a sitter for Resident #11 yelled at her roommate Resident #18; multiple staff members were observed by the surveyor standing by when the incident occurred. The findings included: Cross Refers to F-223 as it relates to the failure of the facility to ensure that staff monitored visitors/sitters interactions with residents to ensure the residents safety and well being in the facility. Resident #18 was allegedly verbally abused by Resident #11's visitor/sitter. Cross Refers to F-225 as it relates to the failure of the facility to report and thoroughly investigate an incident in the facility as possible neglect due to a nurse's inappropriate approach to applying heat to Resident #11's leg that resulted in a burn. Cross Refers to F-281 as it relates to the failure of the facility Nursing staff to verify the physician's orders [REDACTED]. The failure placed Resident #11 at risk of serious harm. Cross Refers to F-323 as it relates to the failure of the facility to provide necessary care for Resident #11. The resident was burned when a nurse used a microwave to heat a compress and placed it directly on the resident's leg without using an appropriate barrier between the resident's leg and the heated compress. This action resulted in a second degree burn to the resident's leg. Cross Refers to F-490 as it relates to the failure of the Administrator to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administrator was aware that a licensed nurse used a microwave to heat a compress and apply it to a resident's leg that resulted in a second degree burn and failed to implement corrective action to ensure resident safety. In addition, the Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures. Cross Refers to F-520 as it relates to the failure of the facility to ensure that the Quality Assurance process was utilized to identify, monitor and implement a plan of correction related to an injury that was the result of applying heat to a resident incorrectly. In addition, the Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures and met regulation. The facility admitted Resident #11with [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders (TO) reveled that Resident #11 had a TO (telephone order) dated 3/11/12 for Heat to knee and a clarification order on 3/11/12 for heat to knee q (every) shift. On 3/27/12 a new TO was written to D/C (discontinue) heat to left knee and orders were given for a treatment to the knee. Review of the facility's Event Report indicated that on 3/27/12 at 10:30 AM the nurse was called to resident's room by (CNA), observed red area with two intact blisters to lt (left) knee. Also on mattress beside resident was a biohazard bag with two washclothes (sic) inside and a pillowcase covering it. Resident currently has tx (treatment) of heat to lt knee q (every) shift. Called 11p-7a nurse on duty last night, ask her how she did heat tx. to resident's knee. She stated 'I wet two washclothes (sic), put them in microwave for 2 minutes then put inside a biohazard bag and wrapped a pillowcase around it and laid it on resident's knee'. On 5/2/2012 at 9:05 AM, during an interview with the Assistant Director of Nursing (ADON), she stated the incident was not reported because the injury was not of unknown origin and the facility did not feel like the nurse intended to cause harm to the resident. No further investigation was done by the facility. The facility admitted Resident #18 on 6/10/11 with [DIAGNOSES REDACTED]. On 5/01/12 at approximately 4 PM the surveyor heard loud yelling on the Gaston Unit. At least four staff members were observed on the unit at the time of yelling. As the State Agency surveyor approached the room from which the yelling was coming, she observed a tall, large male, believed to be a family member of Resident #11, standing over, yelling and pointing his finger at Resident #18 who was seated in a Geri chair. The male looked directly at Resident #18 and stated, You don't talk to her. You don't say anything to her. You all better move her. Prior to the surveyor approaching the room a hospice nurse was observed standing outside the door while the family member yelled at Resident #18. The surveyor in the hallway observed four facility staff members who failed to respond to the family member yelling at Resident #18. The surveyor approached the staff in the hallway and asked, Can anyone hear the yelling going on down the hall? What are you going to do about the family member yelling at the resident? The staff looked at the surveyor and hesitated. CNA (Certified Nursing Assistant) #3 entered the room and the family member and Resident #11 exited the room. The nurse at the medication cart did not attempt to protect Resident #18 from the angry family member. Review of the facility's Policy & Procedure Manual Subject: Abuse and Neglect last revised on July 2010 stated, Policy: .Failure to report shall be cause of disciplinary action . All allegations will be reported to appropriate agencies and services as required by applicable state and federal regulations. The DHEC Certification Division shall be notified within 24 hours of the allegation . Procedure: . 1. Any person having information, either by direct observation or by report, or any act or suspected act that he/she considers may be abuse, neglect or mistreatment of [REDACTED]. Initial reports are to be completed verbally and in a written form on an Incident Report. This Incident Report should be given immediately or as soon as practically possible to the Health Facility Administrator, the Director of Nursing, or his/her designee. The Health Facility Administrator . will initiate an Investigation. 2. Any employee who reports or who receives a report of abuse or neglect must take whatever actions are appropriate to protect the resident from further alleged abuse or neglect. 3. The resident's physician and agent will be notified . A resident who is a victim of alleged abuse or neglect must be immediately assessed by a Licensed Nurse . The clinical record of the resident for whom a suspected abuse/neglect report is completed must contain objective information, facts NOT speculation. 4. The investigation Report is considered a confidential facility report and should include: a. The date, time, location of the alleged incident; b. A complete description of the event . e. A description of any injuries sustained and/or any changes in resident's mental state . h. Action taken . 6. If a family member or other visitor is suspected of abuse, they may not be allowed to visit the resident, or may be required to visit only if a staff member is present . 8. The results of all investigations of substantiated incidents of abuse or neglect will be reported to the Department of Health Licensing and Certification and to all other agencies in accordance with state law within five (5) working days . DEFINITIONS 1. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, or the deprivation by care custodian of goods or services that are necessary to avoid physical harm or mental suffering . 3. Verbal refers to any use of oral, written or gestured language that includes disparaging and derogatory term to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability . 15. Neglect means failure to exercise that degree of care which a reasonable person in a like position would exercise. It includes failure to assist in personal hygiene or the provision of food and clothing, failure to provided medical care for physical and mental health needs, failure to protect from health and safety hazards . Reporting/Response: .All substantiated incidents of abuse or neglect will be reported to the Quality Assurance Committee . On 5/3/12 at 10:30 AM, the Administrator, Director of Nursing, and the Assistant Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 received a burn from a heat treatment which was executed and applied incorrectly. On 5/2/12 at 1:55 PM, the Administrator and the Director Of Nursing were notified of a second Substandard Quality of Care and/or Immediate Jeopardy existing in the facility when an observation was made of a visitor verbally abusing a resident with no staff intervention to protect the resident. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and facility procedures. The Administrator was informed of this on 5/3/12. The citation at F-226 remained at a lower scope and severity of E. |
2016-06-01 |