| 63 |
NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE |
445033 |
1414 COUNTY HOSPITAL RD |
NASHVILLE |
TN |
37218 |
2018-03-28 |
607 |
D |
1 |
0 |
8HII11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility policy, medical record review, review of facility documentation, and staff interview, the facility failed to timely report an injury of unknown origin per policy to facility administration per facility policy; failed to implement facility policy related to training after an allegation of injury of unknown origin; and the facility administration failed to report the allegation of injury of unknown origin within 2 hours to the State Agency (SA) per facility policy. Failing to implement abuse policies had the potential for abuse events to reoccur and put all 176 residents residing in the facility at risk. Findings include: Review of the facility Abuse, Neglect and Misappropriation or Property, policy, revised 8/24/17, revealed the definition of an injury of unknown origin as: .means an injury that meets both of the following conditions: (1) the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury; or the location of the injury. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown source, or suspicion of crime. Directly after assuring that the resident(s) involved in the allegation or abuse event is safe and secure, the alleged perpetrator has been removed from the resident care area, and any needed medical interventions for the resident have been requested/obtained, the charge nurse will inform the Facility Administrator (the abuse coordinator), Director of Nursing (DON), physician and family or resident's representative of the allegation of abuse or suspicion of crime. The facility Administrator will determine whether the report constitutes an allegation of abuse or suspicion of crime as defined in this policy, and, if so, he or she, or the DON, will notify State agencies according to State reporting procedures within two hours. The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegation of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this account. The facility Administrator will make reasonable efforts to determine the root cause of the alleged violation, and will implement corrective action consistent with the investigation findings, and take steps to eliminate any ongoing danger to the resident or residents . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum (MDS) data set [DATE] revealed Resident #10 with severe cognitive impairment and no behaviors. Resident #10 required extensive assist of 1 person for bed mobility, dressing, and eating, and was dependent with 1 person assist for transfers, toilet needs, and bathing. Medical record review of a nursing assessment, completed by Licensed Practical Nurse (LPN) #7, dated 12/29/17 at 1:00 AM, revealed Resident #10 complained of pain and the LPN assessed the resident with swelling and pain in the right arm. The assessment did not indicate if the Administrator, or the DON were notified. Medical record review of a radiology report for Resident #10, dated 12/30/17 and faxed at 7:14 AM, revealed an acute mildly displaced distal humerus fracture. Medical record review of a Nursing Progress Note, dated 12/30/17, written by LPN #7 revealed the night shift nurse reported an x-ray indicating a right arm fracture. The resident was transported to the emergency room at 10:15 AM. The DON and Administrator were contacted as well (first observation of pain and swelling was on 12/29/17 at 1:00 AM). Medical record review of the emergency room Progress Note, dated 12/30/17, revealed a right arm fracture that the physician documented .was not a result of abuse/neglect . Medical record review of a Nursing Progress Note, dated 12/31/17 at 12:08 AM, revealed the .resident returned from the hospital in no acute distress with a right arm splint and arm sling, family at bedside, and pain medication administered with good results . Review of the facility interventions related to the investigation included Abuse Education (MONTH) (YEAR), which included 5 questions related to when to report abuse, signs of abuse, factors increasing the risk of abuse, and common reasons for abuse. Nurses were required to sign they received a copy of the Signature Healthcare's Triage Process. Review of the sign-in sheets for the Abuse Education (YEAR), revealed 137 of 285 listed staff had signed to indicate the training was completed. Review of the facility Positioning Competency, revealed guidelines for assistance for a resident positioning in a bed and chair, and included areas to indicate completion, comments, employee signature, supervisor signature, and yes or no for successful completion. Review of the facility sign-off sheet included completed sign-off for all staff. Upon review of the individual competency sheets revealed multiple sheets were missing dates, evidence the competency was completed, and supervisor signatures. Interview with the DON on 3/28/18 at 1:00 PM in the Conference Room revealed when Certified Nurse Assistant (CNA) #9 came on shift at 11:00 PM the CNA discovered Resident #10 complaining of pain when being turned. CNA #9 reported the issue to LPN #7 and the resident was assessed with [REDACTED]. The Night Shift Supervisor/Registered Nurse (RN) #2 was notified and came to assess the resident. An x-ray was obtained with the results of a right arm fracture. Further interview confirmed the RN did not notify the DON or the Administrator per policy of the injury of unknown origin. Further interview confirmed the facility failed to report the injury of unknown origin to the SA within 2 hours as required and per policy. Interview with the Administrator on 3/28/18 at 1:35 PM in the Conference Room revealed he did not recall the time of notification of the incident. Further interview confirmed he called the DON on 12/30/17 after the x-ray results were received. Further interview revealed the facility began abuse training immediately on the day of discovery. When CNA #8 stated on 1/03/18 the injury might have occurred during positioning the facility felt the injury was caused by faulty positioning, and the facility began staff competencies for positioning. Since the emergency room physician did not think the injury was related to abuse/neglect the facility moved from an allegation of abuse to care competency. Further interview confirmed a delay in notification resulted in the facility not reporting the injury of unknown origin within 2 hours to the SA per facility policy. The Administrator confirmed the abuse training and positioning competencies for nursing were not completed by the facility after the incident. Interview with the DON on 3/28/18 at 2:00 PM in the Conference Room confirmed the abuse training of when to report abuse was not completed for all staff and the positioning competencies were not completed for all nursing staff at the time of the investigation. |
2020-09-01 |