cms_TN: 2391
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2391 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-08-30 | 609 | D | 1 | 0 | BV6Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy review, facility investigation review, medical record review, and interview the facility failed to report an allegation of resident to resident abuse for 2 of 3 (Resident #1 and #2) sampled residents reviewed. The findings include: The facility's ABUSE PREVENTION POLICY & PR[NAME]EDURE policy documented, .It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions .An example of a deliberate (willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach .The investigation protocol must be implemented and a report given to the appropriate agencies as specified by law and regulations . Medical record review revealed Resident #1 was admitted to the secure Dementia unit at the facility on 9/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #1 had a cognitive status score of 8 of 15, indicating moderate impairment and had wandering behaviors. Observations in Resident #1's room on 8/30/19 at 10:10 AM, revealed the resident was ambulatory in her room without assistance, was well groomed and appropriately dressed, had clear speech, and was alert and oriented to person and place. Interview with Resident #1 her room on 8/30/19 at 10:10 AM, when asked if another resident at the facility had hit her, Resident #1 stated, No. Not even the men . Closed medical record review revealed Resident #2 was admitted to the secure Dementia unit in the facility on 7/16/19 with [DIAGNOSES REDACTED]. Review of the 30-day assessment dated [DATE] revealed Resident #2 had a cognitive status score of 0 of 15, indicating severe impairment, had difficulty focusing attention, displayed physical and verbal behavioral symptoms directed toward others, rejected care and wandered. The facility's SUMMARY OF INCIDENT AND INVESTIGATION dated 8/13/19 documented, .CNA (Certified Nursing Assistant) notified nurse on 8/13/19 at approximately 6:30 am that she saw (Named Resident #2) hit (Named Resident #1) on the left forearm 3 times .(Named Resident #2) has a BIM (Brief Interview for Mental Status) of 0 and does not have the ability of mental reasoning to understand what is right or wrong nor does he have the capacity to willfully act in such a manner .After complete investigation, this occurrence was unsubstantiated as abuse. It is determined that (Named Resident #2) did not act deliberately or willfully and that facility staff intervened immediately and appropriately . Review of the facility's investigation revealed Resident #2 was removed from the area immediately and placed on 1:1 observation. The Administrator/Abuse Coordinator was notified of the incident and skin assessment for Resident #1 revealed no bruising and no complaint of pain. Each of the residents' families were notified, the physician was notified and orders were received to transfer Resident #2 to a Psychiatric facility for evaluation and treatment. Telephone interview with CNA #1 on 8/30/19 at 11:55 AM, CNA #1 was asked if she had witnessed Resident #2 hit Resident #1 on 8/13/19. CNA #1 revealed she had heard Resident #1 say a few curse words and saw Resident #2 hit Resident #1 on the left forearm with his fist 3 times. Resident #2 was removed immediately and Resident #1 was assessed and had no complaint of pain or bruising noted. Interview with the Administrator on 8/30/19 at 1:30 PM, in the Administrator Office, the Administrator was asked why the altercation between Resident #1 and Resident #2 on 8/13/19 had not been reported to the State Agency as an abuse allegation. The Administrator confirmed the allegation was not reported to the State Agency and stated she did not report tbecause she determined abuse had not occurred. | 2020-09-01 |