cms_TN: 97
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 97 | NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE | 445033 | 1414 COUNTY HOSPITAL RD | NASHVILLE | TN | 37218 | 2017-09-28 | 225 | J | 1 | 0 | ONHF11 | **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 interview, the facility failed to conduct a thorough investigation for 1 of 4 residents reviewed for abuse. After receiving an allegation of abuse from Resident #2 the facility failed to suspend the accused employee who then worked with the resident on the same night. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment, or death) for Resident #2. F-225 is Substandard Quality of Care The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .allegation of abuse as a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse, as defined in this policy, is occurring, has occurred or plausibly might have occurred .neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated Investigation Guidelines .The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse .injuries of unknown origin source .exploitation .or suspicious crime .6. In cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the resident's unit, or the entire Facility, as appropriate; and shall conduct an appropriate physical assessment of residents who are incapable of being interviewed .10. 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 #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. The MDS revealed no documentation of Resident #2 exhibiting any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17, revealed Resident #2 had a mood Care Plan due to increased confusion and agitation as evidenced by resisting care/combative with staff when attempting to perform care. Resident #2 also had a behavior Care Plan due to being combative with staff while performing care at times, urinating in room, moving belongings from room into hallway and refuses medications at times. Two of the approaches listed on the Care Plan that staff were to use provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Medical record review of Resident #2's Care Plan dated 6/30/17, revealed Resident #2 had bruises on her bilateral forearms and tops of hands and was initiated after the allegation of abuse was made on 6/30/17. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ revealed Resident #2 made an allegation of abuse against Licensed Pratical Nurse #4 (LPN) on 6/30/17. Resident #2 reported LPN #4 came into her room to get her to take 7 pills and she refused because she had her own Dr. (Doctor) She reported the nurse cut her arms to pieces with her claws. Continued review of the Investigative Tool revealed Resident #2 had a history of [REDACTED]. The report indicated Resident #2 had episode slapping meds out of nurse('s) hands. Nurse did hold hand to avoid being hit while getting meds off bed. The facility found there was no incident of harm and that the resident bruises easily. Review of a Witness Statement dated 6/30/17 written by LPN #4 revealed she went in to give her the meds and she slapped the meds off my hand stating she didn't want it. So, I held her hands and scooped up the crushed med off her bed. Review of the investigative documentation provided by the facility for their self-reported abuse allegation against LPN #4 on 6/30/17 revealed the administrative staff interviewed 2 residents regarding their care. Five staff members were interviewed regarding Resident #2 and her behavior on the day of the incident. LPN #4 who was the staff member named in the allegation was not suspended during the investigation per facility protocol and returned to work the same day, working the same assignment area where the resident (who had verbalized fear of the same incident happening again) resides. Review of a Coaching & (and) Counseling Session form dated 6/30/17 revealed LPN #4 was counseled regarding failure to complete proper paperwork regarding medication administration. Review of the Working Schedule for LPN #4 revealed she worked on 6/30/17 clocking in at 6:35 PM and out at 7:22 AM. LPN #4 worked the night shift on B2 which was the 200 Hall with Resident #2 the same day she made an allegation of abuse. Interview with the Administrator on 9/27/17 at 9:30 AM in the conference room confirmed the staff should have reviewed Resident #2's previous skin sheets prior to the incident on 6/30/17 as a part of their investigation and interviewed other staff regarding LPN #4. Continued interview with the Administrator confirmed he believed the investigation was complete and did not suspend LPN #4. Interview with the Administrator revealed it was more likely the skin assessment prior to the incident was inaccurate because the night shift nurse who completed it may not have seen the resident. Further interview confirmed he was under the impression the investigation had been completed and since LPN #4 did not willfully harm the resident they did not suspend her. Interview on 9/27/17 at 1:30 PM by telephone with LPN #4 confirmed she was not suspended after the allegation of abuse by Resident #2 and did not receive any education regarding residents with dementia or combative behaviors. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room confirmed she did not review the investigation regarding the abuse allegation made by Resident #2 on 6/30/17. Continued interview with the Medical Director confirmed the bruises on Resident #2 were not documented beforehand so they were not old bruises, they were new bruises and if a resident described an incident or person as abusive, it needed to be investigated. Further interview with the Medical Director confirmed the facility failed to follow all the steps of the investigative process including suspending the accused nurse. Interview with the Assistant Administrator on 9/28/17 at 1:30 PM in the conference room, confirmed the investigation was completed on 6/30/17 and she cleared LPN #4 to come back to work that night. Continued interview confirmed she did not know if the Investigative Tool needed to be filled out and dated with the date the investigation was completed so she did not document any interview with LPN #4 during the investigation and she did not document findings from the investigation where she cleared her to work that night. Interview with the DON on 9/28/17 at 2:10 PM, in the conference room confirmed staff should not have unnecessary physical contact with residents and if staff were described in the allegation they should be suspended for the course of the investigation. Continued interview confirmed the DON stated if staff were accused of abuse and the allegation was unsubstantiated, then staff should still receive education and training regarding the issue. Refer to F-224 J | 2020-09-01 |