cms_TN: 19
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 19 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2019-05-02 | 609 | D | 1 | 0 | ZMPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure an allegation of abuse was reported immediately to the facility Administrator and to other officials (including the State Survey Agency and Adult Protective Services) for 1 resident (#1) of 4 residents reviewed for Abuse on 4 nursing units of 4 sampled residents. The findings included: Review of facility policy Resident Rights - Abuse of Residents revised 11/14/16 revealed .Reporting .1. Any witnessed or allegations of abuse .must be reported to the Executive Director, Administrator or Charge Nurse/Nurse Supervisor .a. Resident Incidents must be reported immediately .to other officials (including law enforcement, state survey agency, and adult protective services) in accordance with applicable law and regulations . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's 30 day MDS dated [DATE] revealed the resident had severe cognitive impairment. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #3's annual MDS dated [DATE] revealed the resident was cognitively intact. Medical record review of a Psychiatric Progress Note for Resident #3 dated 4/10/19 revealed the resident was attention seeking and inappropriate verbally with staff related to sexuality. Review of a facility investigation dated 4/25/19 revealed Resident #3 reported he witnessed Resident #2 place his hand down the front of Resident #1's pants and Resident #3 told Resident #2 to stop. Continued review revealed Resident #2 replied .I was just checking to see if she (Resident #1) was wet to change . Further review revealed Resident #3 changed details of the alleged incident multiple times during the facility investigation and stated he was not able to see if Resident #2 put his hand under her blanket or inside Resident #1's pants. Continued review revealed Licensed Practical Nurse (LPN) #2 reported while she was feeding Resident #3 in his room on 4/22/19 or 4/23/19, Resident #3 reported the incident to her. Further review revealed Resident #3 also reported the incident to LPN #3 on 4/24/19. Interview with LPN #2 on 5/2/19 at 1:00 PM, in the Administrator's office, confirmed Resident #3 reported the alleged incident to her on 4/22/19 or 4/23/19. Further interview revealed she did not report the allegation because .in my mind .I thought it really didn't happen . Telephone interview with LPN #3 on 5/2/19 at 2:35 PM confirmed she did not report the allegation of abuse because she thought it was .old news . Further interview with LPN #3 confirmed she was aware she should have reported the allegation immediately, but failed to do so. In summary, Resident #3 reported an allegation of abuse to facility staff on 4/22/19 or 4/23/19, but the staff did not report the allegation to the Administrator or the State Survey Agency until 4/25/19. | 2020-09-01 |