| 6644 |
AGAPE NURSING AND REHABILIATION CENTER, LLC |
445162 |
505 N ROAN STREET |
JOHNSON CITY |
TN |
37604 |
2015-01-14 |
226 |
G |
0 |
1 |
WY5111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigation, review of the facility policy, and interview, the facility failed to investigate an injury of unkown origin for one resident (#11) and failed to follow the abuse policy for one resident (#87) of five residents reviewed for abuse, of thirty-three residents reviewed, resulting in physical harm to resident #11 and psychological harm to resident #87. The findings included: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident had [MEDICAL CONDITION] Disease and contractures to all four extremities. Medical record review of a nurse's note dated October 7, 2014, at 5:00 p.m., revealed .R (right) ext (extremity) swollen upper knee swollen .upon palpation to right extremity resident with moaning and facial grimacing-NP (nurse practitioner) notified-NO (new order) .to obtain X-Ray (R) knee and (R) femur . Medical record review of a Radiology Interpretation dated October 7, 2014, revealed .Right Hip .findings: a comminuted fracture (a fracture in which the bone is broken in several places or is shattered, creating numerous fragments) is present in the femoral neck and intratrochanteric region .There is a displacement of the greater trochanter . Review of an Orthopedic consult dated October 7, 2014, revealed, .nursing home resident with (R) intertrochanteric [MEDICAL CONDITION]. non-ambulatory previously. She does have bilateral lower and upper extremity contractures .unsure of mechanism of injury . Interview on January 13, 2015, at 2:48 p.m., with Licensed practical nurse (LPN) #3, in the conference room, revealed the LPN was notified of the change in resident condition by the resident's son at 5:00 p.m., on October 7, 2014. Continued interview revealed the LPN did not notice any changes on the prior assessments completed at 10:00 a.m., and 2:00 p.m. Interview and medical record review with the facility Medical Director on January 14, 2015, at 2:02 p.m., in the bookkeeping office, revealed the resident was at increased risk for a fracture due to age and medication use (no specific medication given), and a fracture could have occurred when the resident was repositioned or moved. Review of the facility policy Abuse Protocol, last reviewed April 2014, revealed .The facility will attempt to identify and proactively correct situations in which abuse is possible . Interview and review with the Administrator and Regional Nurse Consultant on January 14, 2015, at 2:25 p.m., in the bookkeeping office, confirmed the injury was not investigated as an injury of unknown origin. Resident #87 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of a facility investigation dated December 2, 2014, revealed .Date of Occurrence: 12/2/14 .Resident reported to RN (Registered Nurse)(Assessment) Nurse that (resident) was afraid of the 'short, fat, blonde nurse.' (Resident) stated the 'nurse' fussed (at) (resident). The RN (Assessment) Nurse then asked a CNA (Certified Nursing Assistant) to assist (resident) (with) care. The RN (Assessment) Nurse overheard the CNA making rude comments to the resident (and) talking 'short' to the resident .Summary of interview with resident: The resident reported the CNA (named) has threatened (resident), poked (resident) in the back with .finger, told (resident) .wishes (resident) would die (and) told (resident) .doesn't like (resident) .Summary of investigator's findings: Investigation reveals RN Assessment Nurse heard CNA being verbally abusive to resident by stating 'You have made a mess,' and 'you are going to be up in your w/c (wheelchair) all night.' . Review of the resident's statement obtained by the facility from the Director of Nursing (DON) dated December 5, 2014, revealed .Spoke with resident .on 12/3/2014 regarding concern from 12/2/14. Resident states that CNA (named CNA #1) is mean .pokes (resident) in the back .tells (resident) .doesn't like her and fusses at (resident) when (CNA #1) has to clean (resident) up . Medical record review of a Psychiatric Progress Note dated December 8, 2014, revealed .(Patient) readily recalled events with CNA whom (resident) feared, and events were consistent with what (resident) told staff . Review of the facility policy, Abuse Protocol, last reviewed April 2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .Verbal abuse is any use of oral, written or gestured language that is made to Residents directly or within their hearing range, including disparaging or derogatory remarks regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a Resident .Protection .Intervene immediately when you see abuse or neglect, even when you just suspect it, by telling the perpetrator to stop .they should immediately be separated from the Resident . Interview on January 13, 2015, at 9:00 a.m., with the DON, in the conference room, confirmed the resident was able to tell the DON the CNA's name when interviewed, and confirmed the abuse policy was not followed when the resident made an accusation of abuse, the CNA was sent into the resident's room, and the RN did not intervene when overhearing the conversation. Refer to F224 c/o # and # |
2018-05-01 |