| 98 |
NASHVILLE COMMUNITY CARE & REHABILITATION AT BORDE |
445033 |
1414 COUNTY HOSPITAL RD |
NASHVILLE |
TN |
37218 |
2017-09-28 |
226 |
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 facility investigation and interview, the facility failed to implement their abuse policy related to the proper identification, training and investigation of abuse/neglect. The facility failed to operationalize its abuse policy after an allegation of abuse against a resident (#2) by a Licensed Practical Nurse (LPN) #4 was reported. This failure resulted in the potential for continued abuse against residents with whom LPN #4 continued caring for as part of her work assignment. This failure resulted in an 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 #1 and #2. The facility further failed to properly identify neglect regarding Resident #1 as related to not substantiating abuse after Nurse Aide #2 (NA) intervened during resistive care of a resident by using physical force. The facility failed to ensure residents were free from abuse/neglect as per their abuse policy for 2 of 8 residents reviewed (#1, #2). F-226 is Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation of Property, dated 5/22/17 revealed .willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .non-accidental or not reasonably related to the appropriate provision of ordered care and services .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 .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 for Resident #1 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 required extensive assistance of 1 staff for hygiene and scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident as severely cognitively impaired. Review of the Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Property form dated 6/28/17 indicated Resident #1 suffered a distal humerus (upper arm bone) fracture on 6/24/17 because of physical contact with a Nurse Aide #2 (NA). The tool indicated the resident was displaying agitation while staff were attempting to provide care. Alleged employee was attempting to redirect resident and prevent any further agitation while care could be completed. The Investigative Tool indicated the resident was displaying agitation while providing care. She became restless and began swinging her arm at the (NA #2). The NA (#2) redirected the resident by placing the resident's hand down by her side. Due to her [DIAGNOSES REDACTED]. Continued review revealed the incident was not deemed as neglect by the facility. Further review of the Investigative Tool revealed the facility determined Resident #1's combative behavior, her [DIAGNOSES REDACTED]. Continued review of the Investigative Tool revealed the Assistant Administrator documented educated all clinical staff to step away from residents when they become agitated during care. Review of the facility investigation provided by the facility for their self-reported abuse allegation against NA #2 on 6/24/17 revealed the administrative staff did not substantiate the allegation of abuse/neglect. Continued review revealed the facility did not substantiate neglect, even though NA #2 intervened with physical force acting against the facility's policy and procedure for abuse/neglect while providing personal care for Resident #1 where she exhibited aggressive and resistive behaviors toward personal care offered which caused an acute physical injury to occur. Interviews by the surveyor with the two NAs involved in the incident, the Nurse on duty, the Unit Manager and Administrator indicated the events happened in accordance with the Investigative Report filled out by the Assistant Administrator. Interview with the Administrator on 9/26/17 at 3:10 PM in the conference room revealed the facility determined NA #2 did not willfully harm Resident #1 during the incident on 6/24/17. He stated she (NA #2) was suspended and an investigation was completed. Continued interview with the Administrator revealed the facility did not determine neglect had occurred during the incident. Interview with the Medical Director on 9/28/17 at 11:05 AM in the conference room, confirmed the Medical Director reviewed the investigation regarding the incident with Resident #1 on 6/24/17 and stated if a resident had combative behaviors during care she expected the staff to call the Charge Nurse and not force the resident to do anything. Continued interview with the Medical Director confirmed in Resident #1's case a fracture can happen very easily and if NA #2 had not touched her, her arm would not have been fractured. Further interview confirmed if the resident was resisting that much she could have stopped care completely and NA #2 did not use common sense while providing care for Resident #1. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] indicated Resident #2 scored a 4 out of 15 on the BIMS which indicated the resident was severely cognitively impaired. The MDS did not indicate Resident #2 exhibited any behaviors. Medical record review of Resident #2's Care Plan, dated 5/24/17 indicated 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 included provide non-confrontational environment for care and reapproach resident later, when she becomes agitated. Review of a Resident Investigative Tool for Allegation of Abuse, Neglect or Misappropriation of Resident Property with an incomplete date of 7/ indicated Resident #2 made an allegation of abuse against LPN #4 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. Review of the Resident Investigative Tool revealed Resident #2 had a history of [REDACTED]. Continued review revealed the report indicated Resident #2 had episode (of) 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 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. There was no documentation LPN #4 and other staff were provided education or training after the incident. Medical record review of Resident #2's Care Plan dated 6/30/17 indicated Resident #2 had bruises on her bilateral forearms and tops of hands. This Care Plan was initiated after the allegation of abuse was made on 6/30/17. Interview with Nurse Aide (#3) on 9/28/17 at 8:05 AM in an empty resident room on the 200 Hall, confirmed NA #3 did not receive any training or education that she could recall after she reported the incident on 6/30/17 regarding alleged abuse towards Resident #2. Interviews with 6 staff members by the facility revealed Resident #2 described her interaction with LPN #4 similarly. Interviews revealed the resident reported she refused to take medications from LPN #4 and slapped the medications from her hand and reported the Nurse touched her hands and arms. Resident #2 referred to LPN #4 as cutting her arms to pieces with her claws in multiple accounts to different staff members. According to LPN #4's statement and the investigation by the Administrative staff, LPN #4 did have unnecessary physical contact with Resident #2. 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, however he could not confirm the staff received any further education or training regarding this issue. Continued interview with the Administrator confirmed they should have also interviewed other staff and additional residents regarding LPN #4 according to the facility policy. He 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 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 and if a resident described an incident or person as abusive, it needed to be investigated. Further interview confirmed the facility should have followed all the steps of the investigative process including suspending the accused nurse. Interview with the DON on 9/28/17 at 2:10 PM in the conference room revealed the DON was not employed with the facility in (MONTH) (YEAR) and stated if residents have combative behaviors she expects staff to always stop what they are doing, ensure the residents are safe and call for help, reapproach and let the nurse know. Continued interview confirmed if the staff are unable to complete care or give medication then they should document it. Further interview confirmed staff should not have unnecessary physical contact with residents. Refer to F-224 J, F-225 J |
2020-09-01 |