| 14332 |
CRESTVIEW HEALTH AND REHABILITATION |
445409 |
2030 25TH AVE N |
NASHVILLE |
TN |
37208 |
2012-05-15 |
226 |
J |
|
|
LH9611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, medical record review, observation and interview, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. The facility failed to implement procedures that protected RR #1 and Resident #25 from abuse or mistreatment, which resulted in immediate jeopardy as evidenced by displays of emotions due to mental anguish when both residents became tearful when discussing demeaning remarks and actions of staff related to their need for assistance with incontinent care. The findings included: 1. Review of the Abuse Protocol documented "1. Defining... "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (Abuse is also described as acts or omissions, which contribute to, or results in "physical pain, injury, mental anguish, unreasonable confinement, or deprivation of services, which are necessary to maintain the mental and physical health of a vulnerable adult..." 2. Review of the facility's "RESIDENT RIGHTS" statement documented, "...RESIDENT BEHAVIOR AND FACILITY PRACTICES... ABUSE... You have the right to be free from verbal, sexual, physical or mental abuse... STAFF TREATMENT... The facility must implement procedures that protect you from abuse, neglect or mistreatment..." 3. Medical record review for RR #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 4/30/12 documented, "...PROBLEM (ADL's (activity of daily living) /FUNCTIONAL): Self Care Deficit needs ext (extensive) Bed Mobility Transfers Toilet Use... RELATED TO: [MEDICAL CONDITION], Decreased mobility Muscle weakness... MANIFESTED BY: Loss of independence, Incontinence... TOILETING: Extensive assist..." Observations during a resident interview in RR #1's room on 5/8/12 at 2:50 PM, RR #1 began crying when talking about the way the staff spoke to her regarding her incontinence. During an interview in RR #1's room on 5/7/12 at 5:00 PM, RR #1 was asked a series of screening questions to determine if she was of a cognitive level so that she could be interviewed regarding the care and treatment she received at the facility. RR #1 stated that she was here for wound care and therapy and planned to go home to her apartment after she was discharged from the facility. RR #1 was determined to be interviewable. During an interview in RR #1's room on 5/8/12 beginning at 2:50 PM, RR #1 was asked if she felt the staff treated her with respect and dignity. RR #1 stated that some of the Certified Nursing Technicians (CNT) had an "...attitude... I have to use a pamper; and some times I don't ask them to change it because they are hateful... it's only the CNTs (mistreat her)... that has happened everyday since I've been here. They (CNTs) will change their attitude, like they are being so professional, when they get in front of their bosses and stuff. When they (CNTs) have to change my pamper they ask me if I know I'm going to the bathroom. I know I am but, can't get to the bathroom on time by myself..." At 3:10 PM, RR #1 was asked if staff had yelled or been rude to her. RR #1 stated, "...Yes, for using the bathroom on myself..." RR #1 was asked if she knew the names of the staff that spoke to her in a demeaning way and if she had reported it. RR #1 stated, "No." During an interview outside RR #1's room on 5/9/12 at 4:45 PM, RR #1 was asked if she would talk with this surveyor further about the way she was being treated by the CNTs. RR #1 stated, "...I'm not going to be here much longer and don't want to try to do anything about it (the behavior)..." The surveyor asked RR #1 if she knew who to report mistreatment by staff or other residents to. RR #1 stated, "...Yes, the nurse..." During an interview in the Assistant Director of Nursing's office on 5/11/12 at 12:15 PM, the Director of Nursing confirmed that he expected the facility staff to treat the residents with dignity and respect. 3. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 5/8/12 at 10:53 AM, Resident #25 began crying when talking about the way the staff treated her. During an interview in Resident #25's room on 5/8/12 10:53 AM, Resident #25 stated, "...they (staff) steal from you all time. Bloomer gone this morning, socks, magazines..." During an interview in Resident #25's room on 5/8/12 at 11:06 AM, Resident #25 was asked if the staff had been rude to her. Resident #25 stated, "Yes." Resident #25 was asked, "Has staff yelled or been rude to you?" Resident #25 stated, "Yes." Resident #25 began crying and stated, "rather not say cause when you leave, rather not say." During an interview in Resident #25's room on 5/10/12 at 8:00 AM, Resident #25 stated, "(Named CNT #4) on day shift, sometimes she coming in slinging tray on the table, talk snappy to you... Half of them don't speak..." During a telephone interview in the Assistant Director of Nursing's (ADON) office on 5/10/12 at 9:15 AM, Resident #25's daughter stated, "...The tech (CNT) don't know name, said to my mother should call somebody to go to the bathroom and she (my mother) said she had urinated on herself because they were slow in coming. I took it as though they were reprimanding her. The tech did not know I had entered the room... I have mentioned it to the nurse evening shift... Asked her (Nurse #1) where are they (CNTs) and why are they so abrupt... I have talked to (named Nurse #1) at meetings..." During an interview in the Minimum Data Set (MDS) office on 5/10/12 at 4:10 PM, Nurse #1 confirmed that the daughter had talked to her but would not give names. Nurse #1 stated, "We tried to determine who the staff was. It was early part of year or end of last year. We investigated it, me the Social Worker, DON (director of Nursing). It would be in the DON files. From care conference would be in (named Social Worker's) files." During an interview in the ADON's office on 5/14/12 at 8:40 AM, the DON was asked if he found an investigation on staff being abrupt or rude to Resident #25. The DON stated, "I don't have one." 4. The facility failed to implement procedures that protected RR #1 and Resident #25 from abuse or mistreatment, which resulted in immediate jeopardy as evidenced by displays of emotions due to mental anguish when both residents became tearful when discussing demeaning remarks and actions of staff related to need for assistance with incontinent care. 5. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an IJ at F226 with a scope and severity of a "J". The facility's failure to protect residents from psychological harm and the failure to follow the facility policy of reporting and/or investigating allegations of abuse placed Resident #25 and Random Resident #1 at an immediate jeopardy as evidenced by tearful, emotional responses during interviews concerning abuse. An extended survey was completed on 5/15/12. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's office on 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the "Resident Questionnaire Regarding Abuse" form with the following results: a. Ninety residents denied any form of abuse, b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated 2. Investigations were initiated utilizing the Vanguard Event Management process 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention b. Abuse Reporting c. Staff questionnaire on abuse The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 6. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 7. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Weekly At Risk QA/PI Log b. Alert Charting Log c. Event Log 8. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 9. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of "Resident Questionnaire Regarding Abuse", all staff inservices for abuse prevention and abuse reporting and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a "D" level for F226 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag. |
2014-01-01 |