rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
39,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,157,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident, staff and physician interviews and clinical record review, the facility failed to notify the physician timely of a resident incident for one resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifiers: #260. Facility census 145. Findings include: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 10:40 a.m., the DON and Administrator confirmed the lack of timely notification of the physician of a resident incident.",2020-09-01
40,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,164,E,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain visual privacy during one (1) of three (3) dressing change observations for Resident #177. The facility failed to maintain privacy for medication packages for three (3) residents (Resident #38, #195 and #185). Resident identifiers: #177, #38, #195, and #185. Facility census 145. Findings include: a.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., Registered Nurse (RN) #137 and Licensed Practical Nurse (LPN) #64 entered the room to perform the dressing change. Resident #177 was in the bed by the window. The window blind was open and facing at street level a parking lot. RN #137 nor LPN #64 closed the window blind. RN #137 pulled the privacy curtain part of the way around the foot of the bed but leaving the mirror over the sink exposed to the resident's roommate. LPN #64 instructed Resident #177 to roll over onto her stomach. LPN #64 removed the dressing exposing a large stage IV pressure ulcer on the resident's coccyx. RN #137 was preparing the new dressing items. The resident's roommate face was seen in the mirror. The roommate had two (2) visiting family members. The roommate stated, you can pull the curtain, so she can have her privacy. LPN #64 then pulled the curtain completely to provide privacy from the mirror. During an interview, on 02/23/17 at 1:08 p.m., RN #137 stated she had thought about closing the window blind during the dressing change but just didn't do it. RN #137 stated she didn't realize the privacy curtain had not be pulled completely to provide privacy. During an interview, on 02/23/17 at 3:03 p.m., the Director of Nursing (DON) stated her expectation was all staff were to provide full visual privacy during dressing changes. b) A random observation of the 800 Hall on 02/23/17 at 8:15 a.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained the residents full name and medication orders on the pharmacy label: --Resident #38 - [MEDICATION NAME] 200 mg --Resident #195 - [MEDICATION NAME] 30 mg --Resident #185 - Losartan Potassium 50 mg An interview with Registered Nurse-Nurse Manager(RN-NM) #21 on 02/23/17 at 8:15 a.m. revealed the empty medication cards should not have been in the trash. The RN-NM stated once the medication cards are empty they are shredded.",2020-09-01
41,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,272,D,0,1,TKXD11,"Based on staff interview, record review, resident interview, and observation, the facility failed to complete an accurate comprehensive assessment for one (1) of eighteen (18) sample residents. The dental status assessment of one (1) resident was inaccurate on the comprehensive minimum data set (MDS). Resident identifier: #33. Facility census: 145. Findings include: a) Resident #33 During the stage 1 observation and interview of Resident #33 conducted on 02/22/17 at 1:00 p.m., she said she had a broken front tooth and used to wear a partial denture. Her mouth had several teeth in various states of wear and decay, with missing teeth evident. During the medical record review performed on 02/28/17, there were dental consultation notes with the following information: --08/09/16 Exam: Generalized Decay; Generalized Periodontal Disease The attached treatment plan included options for replacing missing teeth, specifically dental implants and partial dentures. --08/30/16 Presents for exam and x ray with extractions Further interview with Resident #33 on 02/28/17 at 10:13 a.m. revealed she was looking into getting a new partial and was awaiting an appointment. On 02/28/17 at 12:30 p.m. a review of the most recent comprehensive (annual) MDS with an assessment reference date (ARD) of 09/24/16 found section L Oral/Dental Status with the following assessment: B. No natural teeth or tooth fragment(s) (edentulous). Registered Nurse Assessment Coordinator #102 was interviewed on 02/28/17 at 1:00 p.m. and said the oral assessment in section L was an error. She provided evidence that a correction was made to the MDS prior to the survey exit.",2020-09-01
42,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,280,D,0,1,TKXD11,"Based on resident interview, medical record review and staff interview, the facility failed to revise a care plan for one (1) of eighteen (18) stage 2 sample residents. The facility did not revise a Brief Interview for Mental Status (BIMS) score. Resident identifier: #12. Facility census 145. Findings include: a) Resident #12 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/02/16 revealed a BIMS score of fifteen (15) which indicates the resident is cognitively intact. The residents most recent care plan indicated a BIMS score of five (5) which indicates severely cognitive impaired. On 02/21/17 at 1:00 p.m., Resident #12 was able to answer stage one interview questions without difficulty. During interview on 02/28/17 at 3:45 p.m., registered nurse (RN) #17 stated the BIMS score on the care plan had not been updated from the residents admission and should have been updated to the current BIMS score of 15.",2020-09-01
43,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,323,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews and review of safety data sheets, the facility failed to prevent accidents by failing to use proper transfer technique for 1 of 1 residents reviewed for accidents, resulting in pain. (Resident #260.) The facility failed to prevent accident hazards by storing chemicals safely (Resident #177.)and storing medications safely. Census 145. The findings are: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--Norco 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and Norco. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 7:07 a.m., NA #81 stated she assisted the resident to the bathroom about 8:30 to 9:30 p.m. NA #81 stated the resident got unsteady when getting off the toilet. NA #81 stated, I grabbed her by the waist and sat her back into the wheelchair. The resident hit her foot on the floor. NA #81 stated the resident asked for pain medication because her foot hurt. NA #81 stated she was supposed to use a gait belt to transfer the resident but did not use it. NA #81 stated some resident's just don't like them. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 at 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 a.m. and she gave the resident Norco for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the administration of the administration. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of timely notification of the physician of a resident incident, the lack of timely assessment of resident injury and administration of medication for pain, the lack of following physician orders [REDACTED]. b.) Resident #177 After completion of a dressing change, on 02/23/17 at 12:00 p.m., RN #137 placed an open bottle of 0.25% acetic acid on the resident's window sill above the resident's heater. During an interview, on 02/23/17 at 1:03 p.m., RN #137 stated she left the acetic acid on the window sill, so other staff could have access to it. I didn't want to put it back in the treatment cart. I thought that would be more of an issue. After the interview, RN #137 removed the acetic acid from the window sill and put it in the locked treatment cart. Review of safety data sheet for acetic acid stated solution is corrosive, Causes severe skin burns, eye damage, may be harmful if swallowed, is flammable and to keep away from heat/sparks/open flames/hot surfaces. c) Medications A random observation of the 200 Hall on 02/23/17 at 7:50 a.m., revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs) --Resident #92 - Phenytoin EX 100 mg (56 capsules) --Resident #184 - Clonidine HCL 0.1 mg (56 tablets) --Resident #187 - Celecoxib 200 mg (56 capsules) An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m. revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. A random observation of the 800 Hall on 02/23/17 at 8:05 a.m. revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for all the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m. revealed the medication cart should always be locked when not in sight of the nurse.",2020-09-01
44,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,371,E,0,1,TKXD11,"Based on observations, staff interview and review of FDA food code, the facility failed to serve foods in a sanitary manner. One (1) dietary aide was serving food with polished nails without wearing gloves and one dietary aide was wearing rings with stones on each hand while serving food. This has the potential to more than an isolated number of residents. Facility census: 145. Findings included: On 02/28/17 at 12:15 p.m., Dietary Aide (DA) #132 was plating resident food. DA #132 had polished finger nails and was not wearing gloves. DA #132 stated her nails were natural and were polished. Additionally, on 02/28/17 at 12:15 p.m., DA #26 was plating resident food on resident trays. DA #26 was wearing a diamond like ring on her left ring finger and a pearl like ring on her right ring finger. DA #26 stated she usually wore the rings when working in the kitchen. The Dietary Supervisor #125 instructed DA #26 to remove her rings. DA #26 removed her rings. The Dietary Supervisor instructed DA #132 to put on gloves, which she did. Review of the 2013 FDA Food Code Chapter 2 page 50 states: Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands.",2020-09-01
45,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,431,E,0,1,TKXD11,"Based on observation and staff interview, the facility failed to properly store medications. The facility did not ensure resident's medications delivered from the pharmacy were put away in a inaccessible and locked area and did not ensure a medication cart on the 800 Hall was locked. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #15, #92, #184, and #187. Facility census: 145. Findings include: a) A random observation of the 200 Hall on 02/23/17 at 7:50 a.m. revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs). --Resident #92 - Phenytoin EX 100 mg (56 capsules). --Resident #184 - Clonidine HCL 0.1 mg (56 tablets). --Resident #187 - Celecoxib 200 mg (56 capsules). An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m., revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. b) A random observation of the 800 Hall on 02/23/17 at 8:05 a.m., revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m., revealed the medication cart should always be locked when not in sight of the nurse.",2020-09-01
46,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,441,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow proper hand hygiene techniques during medication administration for one (1) of twenty six (26) opportunities observed. In addition, the facility failed to perform proper cleaning technique on reusable equipment during one (1) of three (3) dressing change observations. This failed practice affected an isolated number of residents who received medications administered by the facility and of those who had pressure ulcers. Resident identifiers: #126 and #177. Facility census: 145. Findings include: a) Resident #126 An observation of medication administration on 02/28/17 at 08:24 a.m., revealed Licensed Practical Nurse (LPN) #44 attempted to pop a [MEDICATION NAME] 25 milligram (mg) tablet out of the packaging into a medicine cup for Resident #126. The pill missed the cup and fell to the floor. LPN #44 picked up the pill with her bare hands and discarded it. She then popped out a second [MEDICATION NAME] 25 mg tablet into the medication cup and continued with her medication administration for Resident #126 without washing or sanitizing her hands. On 02/28/17 at 10:59 a.m. this matter was discussed with Employee #4, who was responsible for infection control. She agreed that it was an infection control issue. She provided the facility policy titled Handwashing/Hand Hygiene last revised (MONTH) (YEAR). This policy stated to use alcohol-based hand rub or soap and water Before preparing or handling medications. b.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., RN #137 removed scissors from her uniform pocket and cut kling soaked with acetic acid which LPN #64 was using to pack resident #177 coccyx stage IV wound. RN #137 did not clean the scissors prior to use. At the end of the dressing change procedure, RN #137 placed the scissors back into her uniform pocket without cleaning them when she left the room. During an interview, on 2/23/17 at 1:08 pm, RN #137 stated she probably should have cleaned her scissors prior to use and after use. During an interview, on 2/23/17 at 3:03 pm, the Director of Nursing confirmed RN #137 should have cleaned the scissors before and after use during the dressing change.",2020-09-01
47,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,514,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately for two (2) of eighteen (18) sample residents. Behavior monitoring and bowel pattern tracking was not consistently and/or accurately documented for one (1) resident and a second resident had incomplete medication administration records. Resident identifiers: #258 and #260. Facility census: 145. Findings include: a) Resident #258 1. Behavior sheets A medical record review for Resident #258 on 02/27/17 revealed she had physician's orders [REDACTED]. This medication was first administered on 02/03/17 at 8:00 p.m. She also had an order for [REDACTED]. Although the orders were initiated on 02/03/17, the Behavior/Intervention Monthly Flow Sheet were not documented until night shift of 02/04/17 for both [MEDICATION NAME] and [MEDICATION NAME]. In addition, there were multiple blanks holes on both sheets. The director of nursing (DON) was interviewed on 02/27/17 at 4:39 p.m. and she acknowledged the holes on the sheets were where nursing had not completed the forms. 2. Bowel patterns During the medical record review for Resident #258 on 02/27/17, there were several missing entries in the nurse aide documentation for Bowel Patterns. In addition, the documentation reflected no record of the resident having a bowel movement from night shift on 02/17/17 until evening shift on 02/23/17, as the nurse aides had documented 0 meaning No Bowel Movement. Nurse manager #21 was interviewed on 02/28/17 at 3:05 p.m. and she said that the documentation was inaccurate. She also agreed that the holes in the record resulted in the record being incomplete. c.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 from 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 am and she gave the resident [MEDICATION NAME] for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the medication. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of complete and accurate documentation in the clinical record.",2020-09-01
4007,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,223,K,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, incident/accident reports review, facility reportable allegation(s) of abuse review, policy and procedure review, and staff interviews, the facility failed to ensure residents were free from sexual abuse. This was true for seven (7) residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s), who received nonconsensual sexual contact by Residents #10, #11, and/or #62 which were reviewed during the Quality Indicator Survey (QIS) and complaint investigation. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficient practice may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance.) A reasonable person, if touched inappropriately by another person putting hands his down ones pants, touching breasts, and/or rubbing genital area without consent in one's resident home, would feel fear, humiliation, anger, anxiety, and/or stress. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, and #20. Alleged perpetrators: #10, #11, and #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them bene",2020-03-01
4008,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,224,K,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids, and provided no incontinence care. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, #20, and unidentified female residents. Alleged perpetrators: #10, #11, #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he Scared the crap out of her. She said she heard Resident #24 tell him to le",2020-03-01
4009,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,225,E,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, policy and procedure review, accident/incident reports review, allegations of sexual abuse review, and staff interviews, the facility failed to ensure incidents of sexual abuse were identified, thoroughly investigated and reported to the appropriate State agencies. The failure to identify and investigate allegations of sexual abuse also resulted in a failure to ensure alleged victims were protected from further potential abuse. This was true for seven (7) female residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s) who were the recipients of nonconsensual sexual contact by Residents #10, #11, and/or #62. Facility census: 61. Findings include: a) Resident #26 1. Review of the resident's medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (name of Resident #26) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. A review of the report sent to the State agencies contained the immediate reporting form, the five-day follow up report, and the report to the Ombudsman and Adult Protective Services (APS). In an interview with the Social Worker (SW) on 02/24/17 at 11:38 a.m., when asked for the witness statements for this incident, she responded, I don't have any witness statements. When asked if the Director of Nursing (DON) or the Nursing Home Administrator (NHA) would have any additional information such as witness statements, the SW replied No. She stated, I did witness statements a long time ago, but haven't for a while. In addition, when asked about reporting the event between Resident #26 and Resident #62, the SW was asked how she determined this was a resident to resident altercation and not sexual abuse. The SW stated she did not consider it sexual abuse, but agreed in retrospect it was sexual abuse. 2. On 10/06/17 at 10:06 a.m., a nursing entry noted Resident #62 was found reaching for the crotch of Resident #39. Again at 18:47 (6:47 p.m.), Resident #62 was found reaching for the crotch of Resident #39 and residents were separated. An incident report, dated 10/06/16 at 18:40 (6:40 p.m.) stated Resident #62 was observed to forcefully grab 2B's (Resident #26) L (left) arm as she was ambulating via wheelchair past resident. Resident observed to attempt to reach with other hand toward resident's crotch. The Contributing Factors section of the report stated Resident redirected several times to stay away from 2B. Resident sat and watched her go up long hall and back down before grabbing her. The Prevention section of the report stated Resident is continually monitored for sexual inappropriateness against this resident. Residents are separated and whereabouts monitored as closely as possible by staff. This incident report was signed by a Licensed Practical Nurse (LPN #183) and noted to have two (2) witnesses only identified by first name and job title. The physician notification was originally marked as Yes and then marked through with no date/time of notification. The Director of Nursing, Administrator, and Social Worker signed the report on 10/10/16. The Medical Director who was also the attending physician signed the incident report on 11/01/16. The Social Worker, DON and Administrator confirmed this incident of sexual abuse was not reported to any State agency on 02/27/17 at 3:12 p.m. No evidence was found to support the resident was protected from further nonconcensual sexual contact. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's annual MDS with an ARD of 06/16/16, identified the resident had problems with hearing, speaking, and/or vision, and was usually able to make herself understood and to ususally understand others. The resident's Brief Interview for Mental Status (BIMS) score was 99, inidcating the interview could not be completed. BIMS scores on her quarterly MDSs, completed on 09/15/16 and 12/15/16, were 01 and 02 respectively. Both BIMS scores indicated severe cognitive impairment. A continuing review of the medical record for Resident #39 found an amended Monthly Nurse's Notes on 02/05/17 at 17:37 (5:37 p.m.) stating sexual behaviors with male resident. An additional amended Nurse's on the same day at 17:40 (5:40 p.m.) stated touching inapportiatlity (sic) other males. On 02/05/17 at 15:32 (3:32 p.m.) in a CNA/Nurse's Note stated Resident (#10) in female resident room, she (Resident #39) was lying on her bed, male resident sitting on side of her bed, with her hand in his attempting to have her touch him, she attempting to pull her hand away when entering room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. On 02/01/17 at 6:42 p.m. Nurse's Note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated and were showered. The MDS Coordinator stated on 02/03/17 at 9:06 a.m., in a behavior monitoring nurse's note for Resident #10 that the SW, DON and NHA were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. In an interview with the social worker (SW) on 02/28/17 at 11:04 a.m., she stated she had been informed that Resident #10's [MEDICAL CONDITION] bag had come off and Resident #39 had been covered in stool. The SW had been told that when these two (2) residents were in a room together, it was consensual sex. She stated she informed Resident #39's responsible party and was told that sex would not be consensual and there was to be no sexual contact with this resident. Ask if she reported this incident to any of the appropriate State agencies and she stated No. c) Unidentified Female Residents Between (MONTH) (YEAR) and (MONTH) (YEAR), there were twenty (20) incidents where alleged perpetrators Residents #10, #11 and #62 were observed by staff committing non-consensual sexual acts. Through interviews with the Social Worker, Director of Nursing and Administrator, staff interviews, review of accident/incident reports, events reported to the appropriate state agencies and resident medical record review, no evidence was found these events were considered sexual abuse and therefore not reported to the appropriate State agencies. As stated by the Administrator, on 02/28/17 at 3:15 p.m., the system failed. If there were no incident reports completed, the events were not made known to administrative staff to report and investigate and therefore we did not investigate the events and report as per our policy. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found this resident had a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential Interviewees (CI) #3 and CI #4, in separate interviews, said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. Review of the occurrences reported to State Agencies (SA) for the past year found none related to these staff interviews. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and the physician and the administrator on 01/11/17. Review of the occurrences reported to the SAs for (YEAR) and (YEAR) found no evidence this event was reported to the required State Agencies. In an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. The DON telephoned the licensed social worker (LSW), who confirmed there was no report made to State agencies of the 12/08/16 event. The DON said this incident should have been reported to State agencies and investigated, and it was not. She said staff failed to follow the facility's abuse policy. An interview was completed with the licensed social worker (LSW) on 02/28/17 at 2:30 p.m. She said anything that is deemed abuse, neglect, or misappropriation of property is sometimes reported to her. Sometimes she finds it on her own. She said neglect also included not being taken care of by staff, and sexual things. She said she, the DON, the administrator, the nurse manager, and the secretary met daily Monday through Friday. At that meeting, they discussed incidents, but said they do not always get the incidents the day they occur, for whatever reason. The LSW said she was not made aware on 12/08/16 of the incident between Resident #51 and Resident #62. She said had she been made aware of this incident at that time, she would have completed an investigation, and reported to State agencies. d) Resident #49 On 02/22/17 review of the resident's medical record found the most recent quarterly minimum data set (MDS), with assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. In separate confidential interviews with CI#1, CI#2, CI#6, CI#10, and CI#11, all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said she did not witness it, but other staff removed male Resident #11 and male Resident #62 from Resident #49 on 02/20/17. CI #1 said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware those two (2) male residents touched female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI#10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI#11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. Review of the occurrences reported to State agencies for the past year found none related to the incidents described in staff interviews. e) Resident #24 On 02/22/17 medical record review of the most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/26/17, found her Brief Interview for Mental Status (MDS) score was four (4), indicating severe cognitive impairment. The assessment identified she had fluctuation of inattention and disorganized thinking. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents since his admission to the facility. She estimated this to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI#11 said that once over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said Resident #24's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because, He scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. Review of incidents reported to State agencies in the past year found none related to these staff interviews. f) Resident #37 On 02/22/17, review of the resident's annual minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a BIMS score of two (2), indicating severe cognitive impairment. She also had inattention and disorganized thinking present that fluctuates over time assessed. Pertinent [DIAGNOSES REDACTED]. CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she told Resident #62 that he did not need to go into those ladies' rooms, to which he replied, She wanted it. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said she told him no, and he jerked back his hard. Review of the incidents reported to the State agencies for the past year found none related to these staff interviews. g) Resident #1 On 02/22/17, review of the resident's quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/01/16, found her assessed to have a BIMS score of twelve (12). The MDS with an ARD of 12/01/16 assessed her BIMS score as nine (9). Both scores indicated moderately impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. CI#11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on Resident #52's legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. He replied that he did not do anything. She said she reported this to the nurse in charge at the time. Review of the incidents reported to State agencies for the past year found none related to these staff interviews. On 02/22/17 at 10:00 a.m., Resident #1 was playing bingo by herself unassisted in activities, and able to carry on conversation. When asked if any of the men here at the facility have touched her inappropriately in private parts of her body, she replied in the negative. She said she would not put up with that. h) On 02/28/17 at 1:00 p.m., the information received during the confidential interviews was discussed with the director of nursing (DON). The occurrences reported during these interviews were: - One staff member reported witnessing Resident #62 inappropriately touche Resident #51. - One or more staff members said they witnessed Resident #62 and Resident #11 inappropriately touch Resident #49. - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #24. - One or more staff members said they witnessed Resident #10 inappropriately touch Resident #37. - One or more staff members said they witnessed Resident #52 inappropriately touch Resident #1. The DON said she was not made aware by the staff that those female residents were inappropriately touched by those male residents, except for one day recently. She said that on 02/20/17 staff reported that Resident #49 was touched inappropriately by two (2) male residents the same morning. She said staff completed incident reports and reported to State agencies for those two (2) events. The DON said staff should have filed an incident report any time this type of behavior was observed, and this was not done. She said had that been done, then an investigation would have ensued. The DON said their facility policy explained that unwanted sexual touch was sexual abuse, and that those occurrences should be reported to State agencies. She said the reporting to State agencies was not done because there was no incident report completed on inappropriate sexual touching. She said an investigation was not done because there was no incident report completed for those behaviors. She said the first step was getting the incident report completed, and any staff member could begin an incident report. She said she reviewed the incident reports daily. If there are any incident reports which require reporting to State agencies, then those incidents were assigned to the licensed social worker for follow-up. i) During an interview was with the licensed social worker (LSW) on 02/28/17 at 2:30 p.m., it was discussed that one or more staff members in confidential interviews said they had witnessed inappropriate touching of female residents by male residents. Those female residents inappropriately touched were Residents #51, #49, #24, #37, and #1. The LSW said she was aware Residents #62, #11, and #10 had sexual behaviors. She said staff should have completed incident reports each time not only for the male perpetrator, but also for the female victim. She said apparently nurses do not do so. She said there are some things we need to work on and change to ensure the responsible parties of victims were notified, incident reports were completed, and the safety of female residents was ensured. The LSW said she has never heard of any inappropriate touching by Resident #52. She said Resident #52 and Resident #1 liked each other, but they did not even hold hands and she had never seen any inappropriate behaviors between them. j) In an interview on 02/28/17 at 4:38 p.m., the administrator acknowledged facility staff did not identify all issues of inappropriate touching and/or sexual abuse they were aware, or should have been aware of, as abuse situations. She said the lack of incident reports of abuse situations led to the absence of investigation into those issues, and failure to report all incidents of abuse to appropriate state agencies. She agreed that these practices led to the failure to protect some of its female residents from further abuse.",2020-03-01
4010,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,226,K,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids, and provided no incontinence care. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, #20, and unidentified female residents. Alleged perpetrators: #10, #11, #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he Scared the crap out of her. She said she heard Resident #24 tell him to le",2020-03-01
4011,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,241,D,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to promote care for residents in a manner that maintained or enhanced dignity and respect by dating and initialing a wound dressing adhered to a resident's body, and by not clothing a resident from the waist down while in bed. This practice was found for two (2) of twenty-six (26) Stage 2 residents. Resident identifiers: #74 and #49. Facility census: 61. Findings include: a) Resident #74 On 02/21/17 at 9:10 a.m., at the conclusion of wound care/treatment the Assistant Director of Nursing (ADON)/Wound Care nurse secured the wound dressing to Resident #74's coccyx. The ADON then proceeded to write the date and her initials on the wound dressing adhered to Resident #74's bottom. During an interview with the ADON immediately following this observation, she confirmed she had written on the dressing after adhering it to Resident #74's body and should have labeled the dressing prior to applying it to the resident. Wound care observations were reviewed with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m. The DON confirmed the dressing should have been dated and initialed prior to adhering it to Resident #74's bottom. During a review of the wound care observation with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m., she confirmed dating and initialing of the dressing should have been done prior to it being placed on the resident's bottom. b) Resident #49 On 02/22/17 medical record review found the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03), indicating severe cognitive impairment. This resident, who lacked capacity for medical decision-making, had pertinent [DIAGNOSES REDACTED]. On 02/21/17 at 9:50 a.m., an observation of the resident's incontinence care was completed. Nurse Aides (NA) #157 and #145 provided perineal care to the resident, while in the attendance of Licensed Nurse #119. The NAs removed the resident's wet, but far from saturated, disposable brief. After the NAs used cleansing wipes to clean the resident's perineal area and buttocks, the nurse applied Remedy skin protectant. Following this incontinence care, the staff did not apply another brief, underwear, or trousers to the resident. Rather, they covered her with a top sheet and a blanket. The nurse explained that she picks at paper incontinence products and eats it. She said this resident was care planned to wear disposable incontinence products only while up in her chair. For naps and hour of sleep, they placed cloth pads beneath her. When asked if staff put any clothing on the resident's bottom when she went to bed, the nurse replied in the negative. The nurse said the resident did not have enough clothing to put sweat pants on her for times of sleep as she would soil them and go through them quickly. This resident was noted to be the object of nonconsensual sexual contact by a male resident on more than one occasion. During one confidential interview (CI), CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. Upon inquiry as to whether they put panties on the resident when she was bed for dignity, the nurse agreed that would provide her with more dignity. She said she would contact the resident's responsible party about getting her some underpants and bringing them in. Review of a nurse progress note dated 02/21/17 at 10:08 a.m., found the nurse spoke with the resident's sister and asked her to bring this resident underwear when she came in. The nurse noted she said she would bring them in on 02/22/17. The nurse added that the resident needed to wear them when in bed, as she tore/ate pieces of regular disposable briefs. This information was shared with the director of nursing on 02/28/17 at 1:00 p.m. with no further information provided by the exit conference.",2020-03-01
4012,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,253,E,1,0,WA6611,"> Based on observation and resident interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Walls in multiple resident rooms and bathrooms had bubbled and peeling paint, unpainted patches, resident furniture had scratched/marred areas with missing finish in multiple resident rooms. A bathroom door facing had scratched/marred areas with missing paint revealing rust stains on the interior near the floor. Metal plates under the sinks in several resident rooms were not secured and hanging partially open revealing dust and grime. Stained, discolored, and/or cracked tiles were on bathroom floors, showers, and hallways. The vinyl wallboard had separated from the bathroom wall in residents' bathrooms. These findings affected twelve (12) of twenty-four (24) resident rooms and the main hallway on the first floor of the nursing home unit, and two (2) of seventeen (17) resident rooms on the second floor of the nursing home. Room Numbers: #1, #2, #3, #7, #8, #25, #26, #29, #31, #35, #39, #41 #202 and #204. Facility census: 61. Findings include: a) Observation of the facility during Stage 1 and Stage 2 of the Quality Indicator Survey revealed the following rooms had environmental concerns and cosmetic imperfections. 1. Room #1 Large pieces of loose peeling and bubbled paint on the wall between the entrance door and the bathroom door, that broke off easily when touched. 2. Room #2 Bed A had a four (4) drawer chest with scratched areas and missing finish on the veneer. 3. Room #3 There was peeling paint in the bathroom behind the toilet, bubbled paint with holes by the grab bar/safety handle on the right side of the toilet and peeling paint under the resident room sink. 4. Room #7 The chest in the room had a large area measuring 5 inches by 8 inches area with missing veneer finish on the top drawer and scratched/marred edges along the top of chest with missing veneer finish. 5. Room #8 The bathroom door facing had scratched/marred areas with missing paint revealing rust stains on interior near the floor. There were scratched/marred areas on the wall by the toilet, and stained/discolored areas on the floor along the baseboard behind the bathroom door and wall heater. 6. Room #25 An unsecured metal plate under the sink in the resident room hung partially open revealing dust and grime in the rectangular opening. Two (2) very large areas behind bed A were patched, but unpainted. In the bathroom, there was stained and discolored floor tile in the shower with missing grout along the sides and back of the shower floor. 7. Room #26 The vinyl wallboard had separated from the wall on the left side of the bathroom door. 8. Room #29 The vinyl wallboard in the bathroom on the right side of toilet was loose and unsecured at the top, pulling loose from the wall. 9) Room #31 Scratched and missing veneer finish along the top and side of a three (3) drawer chest used by the resident in bed [NAME] 10) Room #35 The bathroom floor around the border was stained and discolored. The bathroom wall near the toilet paper holder had multiple patched unpainted areas. 11) Room #39 A metal plate under the sink in the resident room was not properly secured and hanging partially open revealing dust and grime in the rectangular opening. 12) Room #41 The bathroom wall had multiple patched unpainted areas. The cove molding on the far side of the bathroom was unsecured and hanging from the wall. There were multiple areas of peeling paint on the wall behind bed [NAME] 13) Room #202 The paint on the wall under the sink was loose, chipped/peeling. 14) Room #204 There was bubbled and cracking paint on the wall outside of the bathroom door. Under the sink in the resident's room, there was an area of rough thick plaster patch with areas of cracking. 15) Solarium/dining/activity room on the first floor of the nursing home unit The floor to the entrance of the Solarium/dining/activity room had cracked, stained, and discolored tile. 16) Short hallway on the first floor of the nursing home unit The hallway floor tile located under the water fountain was stained and discolored. At the conclusion of the tour accompanied by the Nursing Home Administrator #114, Maintenance Supervisor #42 and Housekeeping Supervisor #91 on 02/15/17 between 2:40 p.m. to 3:05 p.m., all agreed these observations were in need of repair and/or replaced. When asked whether they were aware of the issues, Maintenance Supervisor #42 stated, Yes, I tour here every day and see this every day, but no repairs have been done.",2020-03-01
4013,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,309,H,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observations, review of incident reports, resident interview, and staff interview, the facility failed ensure female residents were provided care and services to enable them to physical and mental well-being. The facility failed to ensure it had an effective system to ensure incidents of nonconsensual sexual contact were identified and effectively managed to ensure dependent, cognitively impaired women did not experience loss of dignity, or become anxious or fear additional unwanted contacts. As a result of this systemic failure, Residents #26, #39, #51, #49, #24, #37, and #1 were determined to have experienced actual harm. The facility also failed to ensure a resident (#10) received his scheduled daily morning insulin as prescribed by the attending physician. Eight (8) of twenty-six (26) residents were affected. Resident identifiers: #10, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. The MDS identified her as needing extensive assistance of two (2) persons for bed mobility and for transfer, total dependence for dressing, toilet use, personal hygiene, bathing, and limited assistance of one (1) person with eating. She sometimes understood others and could sometimes understand others. Confidential interviewees (CI) CI #3 and CI #4, in separate interviews, both said they had witnessed male Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. This resident lacked capacity and was not interviewable. A reasonable person would be distressed by this type of assault. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents, nor of notification of the resident's responsible party or physician. Review of the facility's [MEDICATION NAME] for (YEAR) and (YEAR) found no evidence this event was reported to state agencies During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said the incident on 12/08/16 was unwanted and should have been deemed sexual abuse. In an interview on 02/28/17 at 2:30 p.m., the licensed social worker (LSW) said anything that was deemed abuse, neglect, or misappropriation of property was sometimes reported to her. Sometimes she found it on her own. She said neglect also included not being taken care of by staff, and sexual things. She said she, the DON, the administrator, the nurse manager, and the secretary met daily Monday through Friday. At that meeting, they discussed incidents, but they did not always get the incidents the day they occurred for whatever reason. b) Resident #49 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. She presented with inattention and disorganized thinking that came and went, and changed in severity. Her speech was unclear. She sometimes understood others, and responded to simple direct communication only. Pertinent [DIAGNOSES REDACTED]. Confidential interviews with confidential interviewees (CI) #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews found all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses report inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents are known to touch female residents inappropriately over their clothing. She said the incidents of 02/20/17 are the first time she has ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked the resident if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs and told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. This resident lacked capacity and was not interviewable. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. c) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/26/17, found her assesse to have a BIMS score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated the resident had severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission, which she estimated to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once over a month ago she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said Resident #24's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. This resident lacked capacity and was not a reliable interviewee for events. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. d) Resident #37 On 02/22/17, review of the annual minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident had a BIMS score of two (2), with inattention and disorganized thinking present that fluctuated over time. A BIMS score of two (2) indicated severely impaired cognitive functioning. The MDS assessment identified she sometimes understood others and was sometimes understood. Pertinent diagnosed included unspecified intellectual disabilities, and unspecified [MEDICAL CONDITION]. CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she told Resident #62 that he did not need to go into those ladies' rooms, to which he replied, She wanted it. CI #4 said she always reported the inappropriate behaviors to the nurse in charge. CI#5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said she told him no, and he jerked back his hard. This resident lacked capacity and was not interviewable for events. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. e) Resident #1 On 02/22/17, review of the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/01/16, found her assessed to have a BIMS score of twelve (12). The MDS with an ARD of 12/01/16 assessed her BIMS score of nine (9). Both scores indicated moderately impaired cognitive functioning. CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on her legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. He replied that he did not do anything. She said she reported this to the nurse in charge at the time. On 02/22/17 at 10:00 a.m., Resident #1 was playing bingo unassisted in activities, and was able to carry on conversation. When asked if any of the men at the facility had touched her inappropriately in private parts of her body, she replied in the negative. She said she would not put up with that. f) On 02/28/17 at 1:00 p.m., the information obtained during confidential interviews with numerous staff members was discussed with the director of nursing (DON). She was informed that one (1) or more of the interviewees said that they had witnessed inappropriate touching of female residents by male residents as follows: - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #51. - One of more staff members said they witnessed Resident #62 and Resident #11 inappropriately touched Resident #49. - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #24. - One or more staff members said they witnessed Resident #10 inappropriately touch Resident #37. - One or more staff members said they witnessed Resident #52 inappropriately touch Resident #1. The DON said she was not made aware by the staff that those female residents were inappropriately touched by those male residents, except for one day recently. She said that on 02/20/17 staff reported that Resident #49 was touched inappropriately by two (2) male residents the same morning. She said staff completed incident reports and reported to State agencies for those two (2) events. The DON said their facility policy explained that unwanted sexual touch was sexual abuse, and that should be reported to state agencies. She said the reporting to state agencies was not done because there was no incident report completed on inappropriate sexual touching. She said an investigation was not done because there was no incident report completed for those behaviors. She said the first step was getting the incident report completed, and any staff member could begin an incident report. She said she reviewed the incident reports daily. If there were any incident reports which require reporting to State agencies, then those incidents were assigned to the licensed social worker for follow-up. g) On 02/28/17 at 2:30 p.m., the licensed social worker was informed that one or more staff members in confidential interviews said they witnessed inappropriate touching of female residents by male residents. Those female residents inappropriately touched were Residents #51, #49, #24, #37, and #1. The LSW said she was aware Residents #62, #11, and #10 had sexual behaviors. She said staff should have completed incident reports each time not only for the male perpetrator, but also for the female victim. She said apparently nurses do not do so - that there were some things they need to work on and change to ensure the appropriate parties were notified, incident reports were completed, and the safety of female residents were ensured. The LSW said she had never heard of any inappropriate touching by Resident #52. She said Resident #52 and Resident #1 like each other, but they did not even hold hands and she had never seen any inappropriate behaviors between them. During an interview with the administrator on 02/28/17 at 4:38 p.m., she acknowledged that facility staff did not identify all issues of inappropriate touching and/or sexual abuse they were aware, or should have been aware of, as abuse situations. She said the lack of incident reports of abuse situations led to the absence of investigation into those issues, and failure to report all incidents of abuse to appropriate State agencies. She agreed that these practices led to the failure to protect some of its female residents from further abuse. h) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] had [DIAGNOSES REDACTED]. Resident #26 began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was not completed. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had the behaviors of inattention and disorganized thinking. In addition, the assessment identified the resident had no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. The Activities of Daily Living (ADL) assessment indicated she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfer, walking in room and had total dependence on staff for dressing, toilet use and personal hygiene. This resident is not interviewable. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated, Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. An approach for the goal, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11, and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occur. When asked how an incident of this type was reported, CI #1 stated they put it in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 was moved to Second Floor (12/02/16) to get her away from the men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26's) pants. Resident #26 was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident-to-resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry noted Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 was again found reaching for the crotch of Resident #26 and the residents were separated. All of the incidents of sexual abuse toward Resident #26 would be upsetting by any reasonable person. The resident's inability to resist the repeated nonconsensual sexual contacts resulted in a determination of actual harm. Although this resident's feelings could not always be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. No evidence was found in the medical record to indicate Resident #26 was assessed after the incidents of sexual abuse. In an interview on 02/22/17 at 2:06 p.m., the Director of Nursing (DON) stated that staff did not complete incident reports regarding the sexual abuse of Resident #26 except for the incident on 08/16/16. In addition, she stated because no incident reports were completed, the sexual abuse was not investigated as stated in facility policy and procedure for abuse reporting. The DON was in agreement Resident #26 should have been assessed following these incidents and evidence recorded in the medical record. i) Resident #39 A review of the medical record from 02/13/17 through 03/01/17 revealed Resident #39 was originally admitted on [DATE], had [DIAGNOSES REDACTED]. Review of the resident's annual MDS with an ARD of 06/16/16 found she had no issues with hearing, speaking, and/or vision. The assessment identified she was usually understood and usually understood others. This resident had a court appointed conservator/guardian as she was not competent to act on her own behalf. The Brief Interview for Mental Status (BIMS) score on annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. The following incidents of sexual abuse by alleged perpetrator Resident #10 were noted in the medical record of Resident #10. No evidence was found of the incidents of sexual abuse and/or an assessment of the condition of Resident #26 in her medical record. - 09/28/16 at 14:06 (12:06 p.m.) - Behavior Monitoring nurse's note stated, Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. The MDS Coordinator stated on 02/03/17 at 9:06 a.m., in a behavior monitoring nurse's note for Resident #10 that the SW, DON, and NHA were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) - a CNA/Nurse's Note stated Resident (#10) in female resident room, she (Resident #39) was lying on her bed, male resident sitting on side of her bed, with her hand in his attempting to have her touch him, she attempting to pull her hand away when entering room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. All of the incidents of sexual abuse toward Resident #39 would be upsetting by any reasonable person. The resident's inability to resist the repeated nonconsensual sexual contacts resulted in a determination of actual harm. Although this resident's feelings could not always be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. No evidence was found in the medical record to indicate Resident #39 was assessed after the incidents of sexual abuse. In an interview with the Director of Nursing (DON) on 02/22/17 at 2:06 p.m., she stated that no incidents reports were completed regarding the sexual abuse of Resident #39. In addition, she stated because no incident reports were completed, the sexual abuse was not investigated as stated in facility policy and procedure for abuse reporting. The DON was in agreement Resident #39 should have been assessed following these incidents and evidence recorded in the medical record. j) Resident #10 Review of the medical record on 02/21/17 at 1:17 p.m. revealed Resident #10 was initially admitted on [DATE]. His [DIAGNOSES REDACTED]. He was prescribed accu-check (blood glucose monitoring) twice a day, with scheduled [MEDICATION NAME]90 units to be administered in the morning and scheduled [MEDICATION NAME]80 units to be administered in the evening at bedtime and [MEDICATION NAME]10 units scheduled to be administered in the morning before breakfast and [MEDICATION NAME]15 units scheduled to be administered in the afternoon before dinner. A Pharmacy consultation report with Comment issued on 12/07/16: Records show on 11/29/16, 12/03/16, 12/04/16 and 12/05/16 no morning [MEDICATION NAME] given. Recommendation: Please educate nursing on importance of proper dosing and [MEDICATION NAME] doses should not be held. Rationale for Recommendation: Basal insulins, such as [MEDICATION NAME] do not affect blood glucose concentrations immediately after administration. The Diabetic Flow Sheet revealed: ---on 11/29/16 at 0641 (6:41 a.m.) an accu-check was performed with a blood glucose result of 117, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 252. ---on 12/03/16 at 0600 (6:00 a.m.) an accu-check was performed with a blood glucose result of 259, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 245. ---on 12/04/16 at 0641 (6:41 a.m.) an accu-check was performed with a blood glucose result of 128, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 243. ---on 12/05/16 at 0600 (6:00 a.m.) an accu-check was performed with a blood glucose result of 69, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered or of blood glucose level being below 70 as ordered. At 2145 (9:45 p.m.) an accu-check was performed with a blood glucose result of 383. After reviewing the Pharmacy consultation report dated 12/07/16 and Diabetic Flow Sheet dated 11/28/16 to 12/07/16 on 02/27/17 at 2:10 p.m., the Director of Nursing (DON) agreed the scheduled morning insulin for Resident #10 was not administered as ordered by the physician. She also verified that no physician notification was conducted by the nurse on any of the days the morning insulin was not administered, because absolutely the physician should have been notified on each of those days. The DON stated, I don't know why the nurse held those doses and just glad that he (Resident #10) did not have any complications arising from the insulin being held. Resident #10 required multiple daily insulin doses and had blood glucose results from 11/29/16 to 12/05/16 ranging from 69 to 259 in the morning and blood glucose results in the evening ranging from 243 to 383 reveling he was considered to be an uncontrolled insulin dependent diabetic. Withholding his morning scheduled insulin doses put the resident at risk for potential complications related to his medical [DIAGNOSES REDACTED].",2020-03-01
4014,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,314,G,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and policy review, the facility failed to provide care and treatment to a resident to promote healing of existing pressure ulcers and to prevent new sores from developing. There was no system in place to ensure skin assessments were completed timely and accurately, that interventions were implemented, monitored, and revised as appropriate, and changes in condition were recognized, evaluated, and reported to the physician, and that staff were knowledgeable in identifying and caring for pressure ulcers. Resident #74 was admitted with pressure ulcers on both elbows and his history identified a recent pressure ulcer to his coccyx. Failure to provide preventative measures resulted in actual harm to the resident by the redevelopment of the sacral pressure ulcer, a deep tissue injury to the left heel, and multiple toe wounds. Additionally, during an observation of wound care for Resident #74's, the nurse did not employ appropriate infection control techniques to reduce the risk of infecting the wound. This affected one (1) of three (3) residents reviewed for pressure ulcers. Resident identifier: #74. Facility census: Findings include: a) Resident #74 1. Review of the resident's medical record at 8:12 a.m. on 02/16/17, revealed this eighty-two (82) year old resident was admitted to the facility on [DATE] from an acute care setting. The acute care discharge summary dated 12/18/16 stated the resident presented to the hospital with increased weakness, loss of appetite and weight loss, and the inability to perform his activities of daily living (ADLs). His discharge [DIAGNOSES REDACTED]. The plan of care included in the discharge summary include, Sacral decubitus ulcer, Protect skin from further breakdown and compromise, and Frequent repositioning, keep patient active, and enforce aggressive wound care. The nursing physical assessment admission note dated 12/19/16 stated Resident #74 was admitted from an acute care center with a history of increased weakness, frequent falls, loss of appetite, rhabdomyolysis (a condition in which damaged skeletal muscle tissue breaks down rapidly), failure to thrive, muscle weakness, incontinence, and a sacral pressure ulcer. The skin assessment described, Left elbow Stage II wound 3 centimeter (cm) circle with hole in middle open purple with serious serioussangus (sic) drainage noted. Right elbow 3 cm round hole 1.25 depth with brownish/tan drainage noted. Buttocks with old red scar right proximal. The resident care record assessment written at 9:57 p.m. on 12/19/16 by Nurse Aide #138 noted Resident #74 was incontinent of bowel and bladder, and required assistance with all ADLs. -- On 12/30/16 the Assistant Director of Nursing (ADON), who was also the wound care nurse, documented a wound assessment in the computerized progress notes that included, bilateral elbows were a stage 2 on admission - now are resolving and only has some redness around perimeter -- On 01/09/17 the ADON documented an assessment stating, Bilateral elbows were noted to have stage 2 pressure ulcers on admission - areas are now dry and slightly red area - continue to use skin prep bilaterally BID (twice a day) [MEDICATION NAME]. -- On 01/16/17 the ADON wrote, Right elbow - slightly pink - open area 0.50 cm round and 0.25 deep - using skin prep - added elbow protectors resident has tendency to lean to right and puts pressure on elbow - very bony all over -- The record was silent for any assessments related to the coccyx/sacral area since the resident's admission on 12/19/16, until 01/25/17. At 6:51 a.m., Nurse Aide (NA) #121 documented, When we turned resident we found he had two sores on his bottom. I reported it to the nurse -- On 01/25/17 at 2:02 p.m. the ADON wrote, A (left elbow per pressure ulcer/location unisex body form) - resolving stage 2 - 4 cm round dk (dark) purple - not open - skin prep and elbow protectors. b (right elbow per pressure ulcer/location unisex body form) resolving stage 2 - 4 cm round dk (dark) purple with open area - 0/10 deep - skin prep - elbow protectors. -- At 3:46 p.m., on 01/25/17 Registered Nurse (RN) #153 documented, Resident has 2 Stage III (3) open areas on buttocks Drsg (dressing) applied and turn resident every two hours to prevent further breakdown. -- On 01/26/17, the Director of Nursing (DON) documented the wound assessment in the section titled Pressure Ulcer Condition: Rt (right) buttocks with 2 open areas red periwound with yellow center. Lt (left) buttocks with 1 open area red periwound with pink center. Rt heel with DTI (deep tissue injury) skin intact. Rt great toe posterior (top) pinpoint open area. All areas no odor noted. Under the section titled Pressure Ulcer Stage, the DON documented: -- A - RT buttocks 0.5 x 0.25 cm Stage 2. -- B - RT buttocks 0.25 cm x -- C - LT buttocks 0.25 cm x -- RT heel - DTI 1 cm x 1 cm unstagable. -- RT Great toe pinpoint area Stage 2. Interventions included heels elevated off of the bed with bilateral heel protectors, pillow for positioning and an air mattress for the bed. Turn every two hours and staff are to notify the physician. -- On 02/06/17, the DON documented a wound assessment evaluation in the computerized records: -- A - RT (right) buttock with open area pink center no drainage, 0.25 cm x 0.25 cm x 0,25 cm Stage 2 -- B - RT buttock no open area pink in color, 0.25 circular area superficial D/I (dry and intact) pink in color Stage 2 -- C - LT buttock no open area pink in color, superficial D/I (dry and intact) pink in color Stage 2 areas with healthy tissue -- D - RT heel DTI intact area drying 1 cm x 1 cm edges intact -- [NAME] - RT great toe pinpoint scabbed area posterior UTD (unable to determine) edges intact unable to determine -- F- RT elbow -- G - LT elbow superficial area pink in color skin intact resolved Stage 2. After reviewing the resident's medical record with the ADON/wound nurse during an interview on 02/16/17 at 9:30 a.m., the ADON confirmed Resident #74 was admitted to the facility after a stay in an acute care center for treatment of [REDACTED]. She agreed the resident was at risk for skin breakdown because he was dependent on staff for all aspects of ADL care, he was incontinent of bowel and bladder, he was thin and bony, and at nutritional risk. The ADON reported he was admitted with pressure ulcers on both elbows, and his buttocks wounds were in-house acquired on 01/25/17. The ADON stated she had no education or training in wound care, nor did she have a mentor she could contact with questions. She reported the facility did not conduct any routine body audits on the residents and there are no wound rounds or scheduled rounds with the physician to evaluate the wounds and discuss treatment options. She selected wound care treatments based on past experiences at other facilities and then notified the physician. The Director of Nursing (DON) reviewed the medical record during an interview at 9:45 a.m. on 02/16/17. She acknowledged Resident #74's skin and wounds were initially assessed on admission on 12/19/16. Weekly skin assessments were not completed. No other wound assessments were documented until 01/26/17 when the wounds were discovered on his buttocks. Registered Nurse (RN) #126 was interviewed on 02/16/17 at 11:30 a.m. She reported Resident #74 was admitted on a regular mattress until he developed the pressure ulcers on his buttocks. The air mattress was started on 01/26/17. The Minimum Data Set (MDS) nurse, interviewed on 02/20/17 at 2:45 p.m., reported she completed Resident #74's Braden assessment on 12/28/16. His score was 13 indicating he was at moderate risk for developing pressure ulcers. At 9:15 a.m. on 02/21/17, the ADON was interviewed in Resident #74's room. Upon request, she pulled back the sheets and found the heel protectors were up on the resident's shins and not protecting his heels. She acknowledged there were new wounds on his toes, which were all related to the sheets on his bed. A follow up interview and observation of Resident #74's feet was conducted with the DON on 02/21/17 at 10:50 a.m. The DON confirmed the wound tracking records lacked complete and accurate documentation of the resident's wounds. Examination of his feet at that time revealed the following: -- left 2nd toe with lateral cut across the anterior aspect below the nail -- abrasion on the anterior of the left third toe -- Right great toe with large scab over bony prominence of the joint The DON reported they need to get a cradle or something to keep the sheets off of his feet. 2. The facility policy titled Preventing Pressure Ulcers included, Any resident with a Braden score of 18 or less will be considered to be at risk of developing pressure ulcers. All residents who are determined to be at risk of breakdown shall have a weekly skin assessment documented . 3. On 02/21/17 at 9:10 a.m., the Assistant Director of Nursing (ADON)/wound care nurse provided wound care to Resident #74's sacral pressure ulcers (3 small open areas). The ADON reported she had already removed the dressing and completed her wound measurements prior to this observation. The following breaches of infection control technique were observed: -- The wound was without protection and covered with a brief containing a small amount of stool near the wound's edge. This provided a potential for introduction of microorganisms into the wounds. -- The ADON placed 2 towels, 5 washcloths, a medicine cup with Dial soap, clean gloves, and a container of Oxivir TB (disinfectant) wipes on an uncovered geri-chair. The geri-chair was an unclean surface, thus contaminating the wound care supplies creating a potential for introducing microorganisms into the resident's wound. -- The ADON donned clean gloves, pulled the cubicle curtain and cleaned 3/4 of the bedside table with the Oxivir TB wipes. At this point, the nurse's gloves were considered contaminated, and to have residue from the disinfectant wipes. -- The ADON placed a bath-basin on the table, added the soap, and placed 3 washcloths on the table next to the basin. The cleanliness of the bath basin could not be assured, which again created an opportunity to introduce microorganisms into the resident's wounds. -- The nurse soaked the first washcloth and scrubbed the resident's bottom in a circular motion moving throughout the wound bed The nurse never addressed the feces other than folding the brief under when she started. This too had the potential to contaminate the wound bed. The ADON placed the first washcloth back in the water in the basin, retrieved a second cloth, and dipped it into the bath basin and padded the resident's bottom. The nurse used the third washcloth to pat the wound area. -- Skin prep was placed around the wound perimeter and a PolyMem dressing (wicks away exudate) applied. The ADON removed her gloves and exited the room to retrieve additional dressing material without washing and/or sanitizing her hands. After reviewing the wound care observations with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m., the DON stated the wound care nurse should have used 4 x 4 sponges with wound cleaner. The use of a bath basin and washcloths increased the risk for infection of the wound. The DON agreed, the ADON should have pulled the curtain before applying gloves, and should have washed her hands after removing the gloves and before exiting the room. When the wound care observations were reviewed with the ADON on 02/28/17, she stated the facility did not have wound cleaner and she did not think to use 4 x 4 sponges. She acknowledged she contaminated the water by placing the soiled washcloth back in the basin and agreed using a basin and washcloths may not be the best infection control practice when performing wound care. She was unaware she had not washed her hands after removing her gloves to retrieve an additional dressing. The ADON acknowledged she had not had any former training in wound care. 4. The facility failed to ensure staff assessing wounds and providing wound care were knowledgeable about pressure ulcers and wound care. Resident #74 was admitted to the facility following care and treatment at an acute care center for generalized weakness, frequent falls, weight loss and failure to thrive. His discharge [DIAGNOSES REDACTED]. All of these factors contributed to the resident's risk of developing pressure ulcers, but the facility failed to implement preventative measures resulting in actual harm to the resident when the sacral pressure ulcer recurred, Stage III pressure ulcers developed to the resident's buttocks, a deep tissue injury developed to the resident's left heel, and pressure areas developed on the resident's toes.",2020-03-01
4015,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,323,E,1,0,WA6611,"> Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The hard plastic-type corridor handrail outside of the pantry room in the first floor main hallway had a missing end piece leaving a sharp jagged edge on the existing center piece. In a resident's bathroom, the grab bar/safety rail on the right side of the toilet was not secured to the wall. In another resident's bathroom, the vinyl wallboard pulled loose from the wall when the grab bar/safety rail was utilized. This had the potential to affect more than an isolated number of residents. Room numbers: #26 and #29. Facility census: 61. Findings include: a) A tour, accompanied by the Nursing Home Administrator #114, Maintenance Supervisor #42, and Housekeeping Supervisor #91 on 02/15/17 between 2:40 p.m. to 3:05 p.m., identified the following issues/concerns: 1. First floor of the nursing home unit -- Outside of the Pantry room door in the main hallway of the first floor of the nursing home unit, utilized by residents as a main thoroughfare, the hard plastic-type corridor handrail had a missing end piece leaving a sharp jagged edge on the existing centerpiece. -- Room #26 In the bathroom, the grab bar/safety rail on the right side of the toilet was loose and not secured to the wall. -- Room #29 In the bathroom, the vinyl wallboard pulled loose from the wall when the attached grab bar/safety rail was grabbed and/or pulled on. At the conclusion of the tour, the Nursing Home Administrator agreed the identified issues were a safety hazard for the residents. When asked whether they were aware of the issues, Maintenance Supervisor #42 stated, Yes I tour here every day and see this every day, but no repairs have been done.",2020-03-01
4016,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,520,F,1,0,WA6612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observations, record reviews and staff interviews, the facility's Quality Assurance process failed to identify compliance issues and develop and implement appropriate plans of action to correct those deficient practices once they had been identified. The revisit survey found the facility had failed to identify and correct deficient practices identified and cited during the annual survey of 03/00/17. The facility's Quality Assurance process had failed to identify those issues with respect to which quality assessment and assurance activities were necessary, and the facility's Quality Assurance process subsequently failed to develop and implement appropriate plans of action to correct those quality deficiencies once they had been identified and cited. Seven (7) of twenty-five (25) deficient practices cited during the annual survey of 03/01/17 were found to remain out of compliance during the revisit survey. This had the potential to affect all residents. Facility census: 55. Findings include: a) The facility failed to operationalize its policies and procedures for training new employees regarding abuse/neglect. Eleven (11) nursing staff members on Unit 3, and the Housekeeping, Dietary, and Maintenance Departments were not included in abuse reporting and sexual abuse training. 1. Abuse Reporting/Sexual Abuse Training On 06/12/17 at 11:07 a.m., after a review of the P[NAME] which stated, Staff have been reeducated on policies and procedures of abuse reporting and notification of changes on 3/2/17 through an outside consulting firm and/or Social Service worker, with all staff having completed reeducation by 4/26/17. Any staff on leave of absence will have reeducation by the Social Worker/designee prior to performing any work duties. A continuing review of the P[NAME] revealed eleven (11) nursing staff members (Employees #110, #109, #105, #101, #100, #95, #68, #64, #63, #103, and #121) who work on the Third Floor (an acute care floor) did not attend the in-service regarding abuse reporting and sexual abuse. In addition, there was no evidence the Housekeeping/Dietary/Laundry/Maintenance Departments attended the in-services. In an interview with the Nursing Home Administrator (NHA) on 06/12/17 at 10:31 a.m., when asked if the Third Floor nursing staff were utilized at times to assist with staffing on the First and Second floors, the NHA responded Yes. When asked were the Third Floor staff and the support departments included in the abuse training, the NHA responded in very loud voice, Were we supposed to? On 06/12/17 at 2:01 p.m., when asked about the participation of the Housekeeping Department in the Abuse Reporting/Sexual Abuse in-service, the Housekeeping Manager stated she was not sure and would investigate to see if the department had attended the in-services. On this same date at 2:25 p.m., the Housekeeping Manager provided a written statement which stated, No abuse inservicing was done for my department. b) All rooms cited in the original survey for failure to maintain a sanitary, orderly, and comfortable interior were inspected accompanied by Administrator, #79 and maintenance personnel #39 on 6/8/17 at 10:00 a.m. Rooms #204 and #26 were not in compliance. room [ROOM NUMBER] had an unsecured covering under the sink in the resident room hanging partially open revealing dust and grime in the rectangular opening. room [ROOM NUMBER] had missing cove molding at the base of the wall between the entry door and the bathroom door. The observations were confirmed by maintenance personnel #39 during the tour. c) The facility failed to ensure psychiatric services were provided to residents with diagnosed mental/psychological disorders and failed to ensure those residents received the appropriate treatment/services to manage assessed problems and emergent behavioral occurrences. In addition the facility failed to ensure staff were provided with guidance regarding identification of triggering events, dealing with escalating behaviors, and interventions to deal with the behaviors of the residents individually. The facility failed to ensure psychiatric services were provided timely and of sufficient frequency to promote the highest practicable level of well-being of the residents. These issues were identified for three (3) of three (3) residents reviewed for psychiatric services. : 1. Resident #83 Review of the medical record on 06/05/17 at 2:18 p.m. revealed this resident was admitted from a neighboring community hospital psychiatric unit to this facility on 04/03/17. His [DIAGNOSES REDACTED]. Physical outbursts. Poor judgment and disinhibition), [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality resulting in hallucinations and delusions. This can also include violence and aggression toward oneself or others), anxiety disorder, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Current medications included [MEDICATION NAME] (an antipsychotic medication used to treat [MEDICAL CONDITIONS] disorder and depression) 50 mg by mouth (po) at bedtime, [MEDICATION NAME] (diuretic medication) 20 mg po twice a day and Klonopin (a benzodiazepine/sedative medication used to treat panic attacks, convulsions and [MEDICAL CONDITION]) 1 mg po twice a day. Resident #83 had been receiving the medication [MEDICATION NAME] on admission, but it had been discontinued on 05/25/17. Review of the psychiatric consults found Physician #115 had visited Resident #83 on 04/20/17. -- A follow-up visit on 05/18/17 under the title Subjective/Objective(typed as written): (Resident #83 name) was seen briefly for follow-up. He has thus far done well but reportedly is a little less tolerant of the disruptive behaviors exhibited by other residents, particularly in the evening when sundowning become a problem. He is of course unable to speak with any real insight about such events in retrospect due to his dense anterograde amnesia. Under the title Plan (typed as written): For now, no treatment changes are required. -- A visit dated 05/25/17 under the title Subjective/Objective(typed as written): Agitation and irritability are reported to have increased but by staff reports this remains largely confined to evening sundowning hours during which other residents tend to become loud, agitated and intrusive. While their behavior tends to agitate him, he is observed to be reasonably kind and supportive of older impaired co-residents . Under the title Plan (typed as written): No treatment changes. Employee #Z commented during a confidential interview that Resident #83, ' .is about to explode.' His behaviors are increasing and you can see the anger in his face. The psychiatrist nor behavioral services are doing anything for him, neither are they advising or recommending interventions for the staff to use to deal with his behaviors which he has had since admission. He (Resident #83) pulled the fire alarm today and when asked about it, he (Resident #83) stated you are not doing anything for me here. Employee #Z stated, It is really terrible when the resident who has mental illness can recognize that he is not getting the treatment he needs or deserves. He is younger than our other residents and a big man that could hurt either himself, other residents or staff. After review of consult reports by Physician #115, Physician #W agreed and verified during a confidential interview that the psychiatric consults under the title: Plan, .Do not constitute a plan because it does not contain recommendations to deal with the behaviors, nor does it provide guidance for the staff as far as what to watch for that may cause behaviors or what to do to if behaviors happen for the staff or attending physician, nor does it provide when or how often the resident will be seen and what the goal of the therapy will be, this should be included with all consult reports. Physician #W stated, I know these issues have been addressed with (Physician #115's name), but as far as addressing the residents as a whole for their psychiatric services they are not being met at this time, it is a work in progress. (Physician #129's name) is at this facility one day a week to see the residents and he is a very busy man. When asked if residents were receiving the services and treatment from behavioral services/psychiatrist that they needed or deserved, Physician #W just looked away and did not reply. On 06/13/17 at 10:45 a.m., Resident #83 sat outside in the courtyard of Nursing Care Facility (NCF) 1 with Employee #75. The Nursing Home Administrator (NHA) went outside and Employee #75 returned to the unit. Also at that time, a Police officer was at the nurses' station speaking with nurses. Visitors were observed using the courtyard as an entrance to the unit in full view of the situation. Immediately after this observation Employee #V reported Resident #83 was having a psychotic break with paranoia, threatening to blow himself and the facility up, and if he had a gun to shoot himself. Resident #83's attending Physician ordered for the police to be called due to the threatening behavior. When asked whether behavioral service or his psychiatrist were involved, Employee #V stated, Are you kidding? It is not the psychiatrist's day to visit the facility and the nurse phoned Behavioral Services and had to leave a message, but they never called back and they won't because there is no help from Behavioral Services even in an emergency. This has happened in the past, not with this resident, but other residents and we are on our own with no help. The sad thing is that any direction that you go out of town there are psych hospitals and facilities that could care for him and provide services and treatment if he (Resident #83) can't get what he needs here, but none have ever been contacted. At 11:35 a.m., Employee #Z commented the resident had a psychotic break and his attending physician instructed the nurse to call the police due to the threatening behavior and to get him out of here to a psychiatric facility designed to take care of this type of behavior and protect the other residents and staff. The employee commented, This has been ongoing since 9:45 a.m. with no resolution. The psychiatrist will not be here until this evening because it is not his day to visit the facility. The Police and Magistrate would do nothing because the facility has in-house psychiatric services so the Police left. Behavioral Services was called and had to leave a message that we had an emergency situation, but they have never responded in the past and they are no help to us even though it is said we have in-house psych services. We cannot get him (Resident #83) inside to try to get him to the emergency department (ED) .we are afraid he will really snap. At 11:40 a.m., a nurse was overheard telephoning the attending physician and notifying him of the continued situation. The nurse received orders for [MEDICATION NAME] (an antipsychotic medication) 5 mg IM (intramuscularly) now, obtain laboratory tests if possible and then transfer to the ED (emergency department) to attempt emergency transport to another facility to provide psychiatric services. At 12:06 p.m. Resident #83 was escorted inside the facility to his room in his wheelchair by the NHA, according to Employee #112 without receiving the medication [MEDICATION NAME] due to being cooperative at this time. An observation of Resident #83 at 1:05 p.m. found him sitting in a wheelchair in his room with his roommate present and no staff monitoring in or outside of his room. During an interview with the NHA on 06/13/17 at 1:47 p.m., when asked whether there was a contract between the facility and behavioral health services, she reported, There is no contract between behavioral health services and the nursing care facility. They are the same entity and provide services whenever needed. It is the same as the hospital providing laboratory or x-ray services or emergency room services, same building same family. Continued medical record review on 06/13/17 at 2:10 p.m. revealed the resident's care plan contained on the date 05/20/17 the resident (typed as written), outside next to ER (emergency room ) dept. (department) for just a few minutes before staff found him next to guardrail. ER dept. called nurse. On the same date (typed as written), Found on elevator by 3rd floor staff stated he was looking for his wife Also on the same date (typed as written), the resident made statements such as, If I had a gun I would shoot myself--staff to be aware and monitor-provide emotional support-redirect . On 05/31/17 it was documented the resident had agitation. Interventions include, staff to monitor if his hallucination/paranoia impose a danger to himself or other residents/intervene/redirect/provide safety . Assess if resident's behavioral/mood symptoms present a danger to the resident and/or others. Intervene as needed. Notify MD (Medical Doctor) as needed . Resident to have appointments with (name of Physician #115) as needed/scheduled Review of the nursing progress notes dated 06/13/17 at 9:45 a.m. found (typed as written): Resident self propelled into courtyard and continued to gate. CNA's (nurse aide) along with nurse went to courtyard to attempt to have resident come inside. Resident told staff to open the gate that he was leaving. (Name of resident) then swung at both male CNA and cursed at them to leave. Nurse gave ok to the CNA's to back away and began talking to him. Resident was rambling about using cologne (which was in his hands) to burn everyone. When asked to come inside due to high temperatures (name of resident) replied that he wanted it to be 150 million degrees so that he would blow up. He then pulled his pressure alarm apart and threw the box across the yard At 9:50 a.m. (typed as written), .(name of attending physician) came down and spoke with him (Resident #83) and he then threatened him (attending physician) .(name of attending physician) gave order to call police to take to hospital . At 10:08 a.m. (typed as written): Police stated that they are unable to subdue this resident. Sheriff's dept. (department) has that responsibility only after papers have been filed with a magistrate to obtain a mental hygiene At 10:15 a.m. (typed as written): (name of attending physician) present states that resident needs to be sent to psych for eval. (evaluation) and that he is not to return here r/t (related to) unable to meet his needs At 10:16 a.m. (typed as written): Call placed to behavioral medicine for (name), psychologist to come and speak with resident. No answer at her office. A voicemail message was left. At 10:19 a.m. (typed as written): .Labs to be sent to (name of hospital in neighboring town) for clearance to be admitted to psych floor. At 12:05 p.m. (typed as written): Attempted to contact Behavioral med. (medicine) regarding resident acute [MEDICAL CONDITION] to request (name of Psychiatrist #115) services. Behavioral med. returned call (name of psychiatrist) not at this facility until 06/15/17 During a confidential interview, Employee #Z reported, Resident #83 went to the ER and was there between 1547 (3:37 p.m.) to 1930 (7:30 p.m.). His labs (laboratory tests) were ok and he was cleared to send to another facility but no facility would accept him. (Name of Medical Director and head of ER) was involved and even calling facilities. He was medicated in the ER and has been 1:1 since he came back to us. Some medications changes were done and he was seen by the psychologist in the ER, which is the first time they (Behavioral Health Services) saw him since this all began yesterday morning. Review of the copies of ER visit notes provided by Employee #107 on 06/14/17 at 9:10 a.m. revealed Resident #83 was seen in the ER at 1629 (4:29 p.m.). The ER Physician's note stated (typed as written): c/o (complaint of) psychotic behavior and is danger to self and others the rest of the documentation was illegible. A document titled Initial Psychiatric Evaluati.2 dated 06/14/17 and electronically signed by Psychologist #131 at 07:15. Under the heading 'Note' (typed as written), Request for consult via (name of ER physician). Patient evaluated. Unoriented. Exhibiting paranoia, delusional thinking. Patient potential risk to both self and others. During a confidential interview on 06/08/17 at 9:23 a.m., Employee #Y explained the procedure for obtaining services from Behavioral Health services. . phone the attending Physician, get an order then tell the Director of Nursing (DON) because she schedules all the appointments. Usually (name of Psychiatrist #115) sees them within a week most of the time is longer, because he (Psychiatrist #115) is only here one day a week. The reasonable expectation is for a resident to be seen within a week, which has gotten better since the survey because before we waited months before anything was done. I can tell you there is no consult report in the chart for the psych visit which is what happens so we never know if he has seen them or not. Which is no big deal because that report doesn't tell us anything anyway other than what we already know that they are having behaviors which is why we call in the first place. The staff here is on their own as to how to deal with any and all behaviors. Most of us are at a disadvantage dealing with most behaviors because we have never worked a psych unit and don't know what to do in an emergency. Behavioral health here is a joke because they don't do anything for the residents and all they and (Psychiatrist #115) say is how busy he is and that he can't be expected to take care of every resident. The sad thing is that any direction that you go out of town there are psych hospitals and facilities that could care for him and provide services and treatment if he (Resident #83) can't get what he needs here, but none have ever been contacted. No outside psych services have ever been contacted and we are only thirty to sixty minutes away from three of them, that could at least come in and do something. Resident #83 was admitted to the facility with known psychiatric and mental illness with behaviors requiring psychiatric care and services. A concise and scheduled psychiatric plan was not made known to the staff providing care and services to the resident related to preventative measures or detailed interventions for exhibited behaviors/moods and/or to deescalate an emergent situation to protect the resident for self-harm and the potential for harm or injury to other residents. During an observed and documented psychotic break no psychiatric services were available for the escalating event for the resident involved and protection for other residents who could have been involved. The staff were able to provide limited care to the resident with no intervention from expert psychiatric services/Behavioral health located within the facility either during or immediately following this crisis. At the conclusion of the survey Resident #83 remained in the facility with 1:1 observation without provided guidance or interventions from psychiatric services regarding any behaviors or mood changes. No other outside psych consults were made if services and/or treatment at the facility were or could not be made available for this resident with behaviors. 2. Resident #29 On the initial tour on 06/05/17 at 10:10 a.m., Resident #29 stated to this Surveyor and Surveyor # , Hello beautiful women or I should say (2) two hot mamas. This was overheard by the Director of Nursing (DON) in the hallway who laughed and stated, I see you have been greeted by (name of Resident #29). Review of the medical record on 06/07/17 at 10:17 a.m. revealed Resident #29 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her current medications included: -- [MEDICATION NAME] (anti-depressant) 40 mg (milligrams) po (by mouth) at HS (bedtime), -- [MEDICATION NAME] (for the treatment of [REDACTED]. -- [MEDICATION NAME] XR (for treatment of [REDACTED]. -- [MEDICATION NAME] 0.25 mg po BID prn (as needed) for anxiety. The medication [MEDICATION NAME] originally was prescribed as 30 mg po at bedtime to decrease libido (sexual desires) on 04/20/17. The medication was increased to 40 mg po on 05/18/17 and then decreased to 20 mg po daily on 06/10/17. Resident #29's behaviors included attempted elopement, nervousness, crying, confusion, and inappropriate conversation. Review of the nursing progress notes revealed (typed as written): -- 04/27/17 - She was seen by (name of Psychiatrist #115) 03/21/17 due to inappropriate comments about sex, etc., to visitors/staff and then was placed on [MEDICATION NAME] (her [MEDICATION NAME] was d/c) to help decrease libido. (Name of Psychiatrist #115) thought it may decrease libido but probably not reduce her flirtatious behavior. -- 05/19/17 - The Maintenance Director reported, .she smacked me on the butt earlier and then she tried to kiss me. Just wanted to report to you. Resident in hallway no abnormal behavior noted. This was the day after [MEDICATION NAME] was increased to 40 mg -- 05/23/17 - a progress note described a behavior monitoring at 0230 (2:30 a.m.) included, .the resident was found by a CNA (certified nurse aide) standing beside her roommate's bed and yelling -- the roommate stated I just can't handle it anymore. I could just kill her -- she turned and went back to bed. Called (name of Behavioral Health Services) for approval for psych consult regarding residents behaviors referral will be made for (name of Psychiatrist #115). -- 05/28/17 at 1716 (5:16 p.m.) .Resident in dining room at this time. Other resident's family in to visit. Resident (Resident #29) being inappropriate towards family members. Resident redirected. -- 06/01/17 at 1249 (12:49 p.m.) (name of attending Physician) gave order to have (name of Psychiatrist #127). At 1252 (12:52 p.m.) Called (Behavioral Health Services) and spoke with (name of person). Made aware that (name of Resident #29) needed to be seen. (Name of person) stated that she is already on his follow up list and resident should be seen this afternoon. Review of the consult reports found only a consult report by Psychiatrist #115 dated 03/21/17. During a confidential interview on 06/08/17 at 9:23 a.m., Employee #Y explained the procedure for obtaining services from Behavioral Health services. Phone the attending Physician, get an order then tell the Director of Nursing (DON) because she schedules all the appointments. Usually (name of Psychiatrist #115) sees them within a week most of the time is longer, because he (Psychiatrist #115) is only here one day a week. The reasonable expectation is for a resident to be seen within a week, which has gotten better since the survey because before we waited months before anything was done. I can tell you there is no consult report in the chart for the psych visit which is what happens so we never know if he has seen them or not. Which is no big deal because that report doesn't tell us anything anyway other than what we already know that they are having behaviors which is why we call in the first place. The staff here is on their own as to how to deal with any and all behaviors. Most of us are at a disadvantage dealing with most behaviors because we have never worked a psych unit and don't know what to do in an emergency. Plus, (name of Resident #29) is always making inappropriate sexual comments and gestures toward family members of other residents which includes children sometimes, other residents and anyone new that comes on the unit. We were told that is the way she is just deal with it as best you can and apologize to the family members. What kind of psychiatrist does that without giving us some type of guidance or directives to deal with the behaviors. Behavioral health here is a joke because they don't do anything for the residents and all they and (Psychiatrist #115) say is how busy he is and that he can't be expected to take care of every resident. The sad thing is that any direction that you go out of town there are psych hospitals and facilities that could care for her and provide services and treatment if she can't get what he needs here, but none have ever been contacted. No outside psych services have ever been contacted and we are only thirty to sixty minutes away from three of them, that could at least come in and do something. The DON reported on 06/12/17 at 12:18 p.m. after inquiry if a psychiatrist consult was performed after an order obtained on 06/01/17, Yes, I have a consult report waiting to have clarification on his recommendations which are not clear. She further stated, Yes there is a communication problem with the psych department here. The medical director has been notified of the issue with (name of Psychiatrist #115) and we were told that (name of Psychiatrist #115) has been spoken to by the medical director but there are no changes. Yes, it is very frustrating because the consults don't get on the chart because I have to wait to clarify his recommendations which in this case involve medications that he prescribed but the recommendations are incorrect involving the present medications that she is receiving. This is because he only comes to our units one day a week no matter what is going on here. The psych department and Behavioral Health services is not a good mix for our residents. It is my expectation that if a resident has increased behaviors they should be seen immediately but that is impossible with a psych doctor coming only once a week because he has residents throughout the facility and in outpatient. We could utilize (name of Psychologist #131), but that is not always possible either because sometimes she is not a good mix for our residents and again sees patients throughout the facility and informs us that the outpatients are more important. So, in other words we have a Behavioral health department in our facility that is not meeting the needs of our residents because it is not able to be utilized ninety-nine percent (99%) of the time. Sometimes he (name of Psychiatrist #115) sees residents on a scheduled time but we never know when that is because nothing is ever in the consult report about future visits or how often they are going to be seen. I have waited almost 2 weeks to get this clarified because he cannot be contacted and the resident is no longer on the medication [MEDICATION NAME], it was changed by him (Psychiatrist #115) to [MEDICATION NAME] and I don't know if he wants the [MEDICATION NAME] given with the [MEDICATION NAME] A copy of the psych consult by Psychiatrist #115 was immediately provided after the interview. A review of the consult report revealed Resident #29 was visited by Psychiatrist #115 on 06/01/17. Under the title Subjective/Objective (typed as written): .However, she insisted on hugging me when I entered and spoke of shoving a boob into you. Whatever the question or comment on my part, she nearly always turned the discussion to sexual content, although she did not directly propose sexual contact beyond the above statement. Under the title Plan (typed as written): Behavioral/environmental interventions have generally not been found effective in frotteurism (a sexual disorder in which a person derives sexual gratification by rubbing against a non-consenting person or object for sexual pleasure) and related sexually unacceptable behaviors in dementia patients of either gender. Suggest reduction of [MEDICATION NAME] ([MEDICATION NAME] can be used for depression and [MEDICAL CONDITION]) to 20 mg qd (every day) and initiation of [MEDICATION NAME] (sometimes used to treat patients with treatment-resistant mood and anxiety disorders) 300 mg po tid (three times a day). Will follow. During a follow-up interview and after review of the consult report on 06/12/17 at 12:30 p.m., the DON stated, No that is not a plan for the staff to follow and doesn't give any plan for the staff to follow and the medications are incorrect. We have had problems in the past with these consults and not having plans listed that could be followed by the staff and the medical director has spoken with him. Inquired if the behavioral health ca not adequately take care of the residents needs why another consult from another psych department has not been consulted, she replied, Because they keep telling us we have a psych department here and no outside psych department has ever been contacted unless we just send them to another facility. Yes, I am sure that there are numerous outside consults that could be done. Employee #X reported during a confidential interview after reviewing the consult from Psychiatrist #115, That is not a plan for a resident and even has the wrong current medications on it. No, her psych needs and behavior needs are not being met by the facility or by the psych/Behavior Health department. I know that if an employee's son comes here, he has to be escorted out of the facility because she (Resident #29) will gravitate toward him and either touch him inappropriately or make numerous sexual inappropriate comments. This happens to visitors, staff and other residents and the staff try to keep her away from the male residents and redirect her. At the time of exit for this survey no evidence for clarification of the consult report dated 06/01/17 for the medications was presented. The facility failed to ensure Resident #29 received adequate psych/behavioral health services and/or treatments to minimize or treatment her ongoing verbal and/or physical inappropriate sexual behaviors toward visitors, staff and other residents even though Psychiatrist #115 stated in his consult that .interventions have generally not been found effective . no other recourse other than pharmacological interventions are being pursued. A clear concise plan for psych services/treatment was not outlined or recommended for this resident including scheduled visits. The ability to contact the Psychiatrist for medication clarification was delayed due to the facility's inability to contact the Psychiatrist and/or Psychiatrist availability in the facility. The needs of Resident #29 were not found to be met by the facility Behavioral Health/psych services to either minimize or control her behaviors consistently putting visitors, residents and staff at risk for her targeted behaviors. Also, putting Resident #29 at risk for being isolated from group and individual socialization due to her inappropriate behaviors by interventions of redirection, remove from male residents and remove from the situation. There was no evidence that outside psych services were contacted for services and/or treatment to assist with providing psych services and consultation to this resident for management of her behaviors. 3. Resident #34 Review of the resident's medical record on 06/06/17 at 11:09 a.m., revealed Resident #34 was admitted to the facility in 2011 with a [DIAGNOSES REDACTED]. The 'History of present illness' stated, pt (patient) has a long Hx (history) of psychiatric disease and lacks (illegible) independent living, pt is here for placement The minimum data set (MDS) assessment with an assessment reference date (ARD of 05/11/17 n",2020-03-01
4037,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,157,E,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify the resident's responsible party and/or physician of incidents of sexual abuse. This was evident for seven (7) of eight (8) residents reviewed for abuse. Resident identifiers: #51, #49, #24, #37, #1, #39, #26, #10, #62, #52, and #11. Facility census: 61. Findings include: a) Resident #51 Confidential Interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. An incident report dated 12/08/16, described that Resident #51 was sitting in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt, and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents. There was no evidence the facility informed the responsible party or the physician of these occurrences. b) Resident #49 During separate confidential interviews with CI #1, CI #2, CI #6, CI #10, and CI #11, all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both separated from Resident #49 on 02/20/17 by other staff, but did not witness it herself. CI #1 said the nurses' reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff was aware that those two (2) male residents touched female residents inappropriately over their clothing. She said the incidents of the morning of 02/20/17 were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and went real slow when he saw a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked the resident if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI#11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. The DON said staff should have filed an incident report any time this type of behavior was observed. She said had that been done, an investigation would have ensued. As part of the investigation, the family members and the physician would have been notified of the incidents. The DON reviewed the computer and her records, and said she found no other incident reports for this resident, and subsequently no evidence of notification of the resident's responsible party or the physician. c) Resident #24 During an interview, CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility, which she estimated as about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate him touching her. CI#11 said that once over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the covers were off the resident, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI#11 said she reported this to the nurse in charge at the time. During an interview on 02/28/17 at 1:00 p.m., the DON said staff had not made her aware that a male resident(s) had inappropriately touched this female resident. The DON reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of responsible party or physician notification. d) Resident #37 CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said the resident told him, No, and he jerked back his hand. During an interview on 02/28/17 at 1:00 p.m., the DON said she was not aware a male resident had inappropriately touched Resident #37. The DON reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of notification of the responsible party MPOA or physician. The DON said staff should have filed an incident report any time this type of behavior occurred. She said had that been done, an investigation would have ensued, and as part of the investigation, the family members and the physician notified. e) Resident #1 CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on Resident #1's legs and inner thighs. She said she reported this to the nurse in charge at the time. During an interview with the DON on 02/28/17 at 1:00 p.m., she reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of MPOA or physician notification. The DON said staff should have filed an incident report any time this type of behavior was observed. She said had that been done, then an investigation would have ensued. As part of the investigation, the family members and the physician would have been notified of the incidents. f) Resident #39 Medical record review found on10/09/16 at 6:46 a.m., Resident #11's behavior monitoring nurses' notes stated, Alert and oriented . Resident was up adlib (as desired) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from Resident 29B. Review of Resident #39's medical record, incident/accident reports, and reports made to State agencies, found no evidence the resident's responsible party was notified of the incident. g) Resident #26 On 10/06/16 at 18:40 (6:40 p.m.), an incident report noted Resident #62 (a male) was observed forcefully grabbing Resident #26 left arm. According to the report, Resident #62 attempted to reach Resident #26's crotch. At 18:47 (6:47 p.m.), Resident #62 was again found reaching for the crotch of Resident #26. Staff separated the residents and Resident #26 was transferred to the Second Floor. Review of Resident #26's medical record review, incident/accident review, and review of reports made to State agencies, found no evidence the facility notified the resident's responsible party of these incidents. h) Resident #62 An incident report identified the alleged perpetrator as Resident #62. Additional evidence was found when the SW noted On (MONTH) 16, (YEAR) (Resident #26's name - a female) was found in the hallway with another male resident. The male resident had his hand down Resident #26s pants. Resident #26 was attempting to get away from the male. Staff moved Resident #26 away from the male. - 10/05/16 at 13:16 (1:16 p.m.) An Activities note stated Resident #62 was redirected at two (2) different times when he had his hand between an unidentified female resident's legs. - 10/06/16 at 10:06 a.m., a nurse noted Resident #62 was found reaching for the crotch of Resident #26. Again, at 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated and continued to follow. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes stated, Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurse's Note stated, Caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m., Hands in female's private parts. -02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated, Housekeeper reported separated touching female resident inappropriately. During the medical record review, incident/accident review, and review of reports made to State agencies, found no evidence the facility notified the resident's responsible party of these incidents. i) Resident #10 This quarterly MDS also identified Resident #10 as having exhibited physical behaviors directed toward others, which included abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of his medical record found the following: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note stated, Sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended entry noted, Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurses' notes stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident's room sitting on the bed with her. Staff told him he might want to come out for the gospel music, which he did. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses' notes stated Resident (#10) found by CNAs (certified nurse aides) in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses' Notes stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurse's note stated, Resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence 'where he was feeling up women today.' The resident was asked why he did this and said 'because they wanted it.' Resident #10 was told, 'No they didn't' and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurses' notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated Found (resident name #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up Resident #10's pants. They would not stay up. Resident #10 began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurse's note stated, Resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurses notes stated, 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. - 02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurse's note written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. - 02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Note stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. Review of the resident's medical record, incident/accident reports, and review of reports made to State agencies found no evidence Resident #10's responsible party was informed of any of these occurrences. j) Resident #11 Medical record review on 02/22/17 at 9:00 p.m. revealed the following about this male resident: - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated, Alert and oriented . Resident was up adlib (as desired) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurse's note for Resident #11 stated, Resident self-propelled wheelchair to up beside an unidentified female resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' Review of the resident's medical record, incident/accident reports, and review of reports made to State agencies found no evidence Resident #11's responsible party was informed of any of these occurrences. k) In an interview with the Director of Nursing (DON) on 02/22/17 at 2:10 p.m., when asked to clarify if there was any information she could provide regarding notification of responsible parties when an incident of sexual abuse occurred, she stated No. When asked if an incident report had been completed would the incident report indicate the responsible party had been notified and she stated Yes, if an incident report had been completed.",2020-02-01
4038,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,252,E,0,1,WA6611,"Based on observation and staff interview, the facility failed to provide a homelike environment for residents by not having tablecloths and/or place mats on the dining tables. In addition, dinnerware and flatware were not removed from the individual serving trays during the breakfast meal. This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) On 02/14/17 at 8:33 a.m., a second dining observation of the breakfast meal on the first floor of the nursing home unit revealed twenty-five (25) residents seated at various tables in the dining room/solarium/activity room. The plastic tables and wooden tables did not have tablecloths or place mats covering the surfaces of the tables. Staff served the residents' breakfast meals with the dinnerware, flatware, and other items left on the individual serving trays. At 8:40 a.m. on 02/14/17, after observing the breakfast meal service on the first floor dining room/solarium/activity room, the Assistant Director of Nursing (ADON)/Wound Nurse #112 agreed it was not a homelike environment for dining. She stated, They are being served cafeteria style and we only have fine dining for lunch with tablecloths and removing the plates from the trays. She further commented that she would ensure this dining practice would be corrected for all meals. .",2020-02-01
4039,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,272,C,0,1,WA6611,"Based on Minimum Data Set (MDS) review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), and staff interview, the facility failed to provide the dates of information used to complete the Care Area Assessments (CAA) for five (5) of five (5) residents reviewed during Stage 2. This affected all residents residing in the facility. Resident identifiers: #39, #26, #62, #11, and #10. Facility census: 61. Findings include: a) Resident #39 On 02/28/17 at 2:16 p.m., a review of the resident's annual MDS with an assessment reference date (ARD) of 06/16/16 revealed the CAA summary contained no dates of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record and see H&P (history and physical), but did not identify the dates of the referenced documents, interviews, or observations. b) Resident #26 A significant change MDS with an ARD of 11/25/16, contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. c) Resident #62 A significant change MDS with an ARD of 11/25/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. d) Resident #11 The resident's admission MDS with an ARD of 09/08/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained, interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. e) Resident #10 The annual MDS with an ARD of 03/24/16, contained no dates of the location of the CAA documentation. Areas that were triggered and marked to be care planned contained interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. f) In an interview with the MDS Coordinator, on 02/28/17 at 1:25 p.m., she confirmed the only information completed in the CAA Summaries were, interview/ record, record, interview, H&P, MAR, observation, but did not include the date of the location of the CAA documentation. She further explained she had a worksheet for each resident and each MDS, but this worksheet was not part of the medical record. She stated she followed this procedure for all MDSs for all residents. g) Review of the RAI Manual and instructions on the MDS form found the instructions for completing Section V include: Page V-5 For each triggered care area, indicate the date and location of the CAA documentation in the Location and Date of CAA Documentation column. Page V-5 Item Rationale Items V0200A 01 through 20 document which triggered care areas require further assessment, decision as to whether or not a triggered care area is addressed in the resident care plan, and the location and date of CAA documentation. The CAA Summary documents the interdisciplinary team's and the resident, resident's family or representative's final decision(s) on which triggered care areas will be addressed in the care plan. Page 4-7 Use the Location and Date of CAA Documentation column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision making documentation can be found in the resident's record. Also indicate in the column Care Planning Decision whether the triggered care area is addressed in the care plan. The MDS form, item V0200 instructions include, 3. Indicated in the Location and Date of CAA Documentation column where information related to the CAA can be found",2020-02-01
4040,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,279,D,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive and/or initial care plans based on the residents' current health condition/status that included measurable objectives and timetables to meet the resident's medical, nursing and psychosocial needs. Care plans lacked individualized goals and interventions for residents with, or at risk for pressure ulcers (Residents #74 and #75), and for a resident (#49) receiving antipsychotic medications. This practice was identified for three (3) of twenty-six (26) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #74, #75, and #49. Facility census: 61. Findings include: a) Resident #74 On 02/16/17 at 8:12 a.m., medical record review revealed this eighty-two (82) year old man was admitted to the facility after a thirteen (13) day stay in an acute care facility. The acute care hospital's discharge summary dated 12/18/16 listed [DIAGNOSES REDACTED]. The plan of care written in the discharge summary identified Resident #74's sacral decubitus ulcer. The plan stated, Protect skin from further breakdown and compromise. The interventions were, Frequent repositioning, keep patient active, and enforce aggressive wound care. The facility's admission physical assessment, written on 12/19/16 at 5:13 p.m. by Registered Nurse (RN) #153, stated, [AGE] year old male discharged from (Name) hospital and admitted to (Name) Nursing Care Facility II .with HX (history): Increased weakness. Pressure ulcers of sacral region .Incontinent to bowel and bladder .wears brief .Buttocks with old scar right proximal. Will continue to monitor. The Nurse Aide resident care record dated 12/19/16 at 9:57 p.m. noted Resident #74 required the assistance of one (1) with turning and repositioning, was a two (2) person transfer with a lift device, required assistance with all other activities of daily living (ADLS) including eating, and was incontinent of bowel and bladder. The initial interim care plan dated 12/19/16, and the current care plan dated 12/29/16, did not identify Resident #74's sacral pressure ulcer and the potential risk of recurrent skin breakdown in this area until he developed two (2) new Stage II pressure ulcers on his buttocks. The facility did not establish individualized measurable goals and interventions to meet the immediate needs of this resident at the time of admission for the identified recent sacral pressure ulcer. The facility did not implement any preventative measures until after staff identified the pressure ulcers on his buttocks on 01/25/17. During an interview on 02/20/17 at 2:45 p.m., the Minimum Data Set (MDS) nurse reported she completed the Braden skin assessment during her MDS review and placed the interventions in the care plan. The MDS nurse reviewed the medical records and reported Resident #74's Braden score was thirteen (13) on 12/28/16, and acknowledged Resident #74 was at moderate risk for skin breakdown. She agreed the interim care plan initiated on 12/19/16 and updated 12/21/16, and the typed care plan dated 12/29/16, did not address Resident #74's history of a sacral pressure ulcer and risks of developing additional pressure ulcers. b) Resident #75 Review of the resident's medical record on 02/20/17 at 1:43 p.m. revealed this resident, admitted on [DATE] and discharged to home on 01/18/17, had [DIAGNOSES REDACTED]. The wound/pressure ulcer forms for the resident contained the following wound descriptions: -- 12/27/17 the wound size was documented as 1 cm (centimeter) x (by) 1 cm -- 01/02/17 the wound size was documented as 0.25 cm round -- 01/9/17 the wound was documented as not open -- 01/16/17 the wound was documented as not open The resident's care plan contained no individualized goals and interventions regarding pressure ulcer assessment, monitoring, prevention, or treatment. After reviewing the care plan for Resident #75, the Assistant Director of Nursing (ADON), who was also the Wound Nurse stated, No the care plan does not say anything about assessment and treatment, I didn't know it was supposed to say anything about how often it is to be looked at. I guess I have a lot to learn with this wound care thing. c) Resident #49 Medical record review on 02/15/17 found [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of the care plan revealed goals that were not individualized related to the [MEDICAL CONDITION] medications. The facility care planned [MEDICATION NAME] usage and the potential for complications/side effects related to its use. The facility did not develop an individualized goal for what it hoped to achieve with the use of [MEDICATION NAME], rather, the goal was for the side effects to be minimal related to the use of the medication. The facility care planned as a problem that she received antidepressant medication related to depression. The facility did not develop a care plan with an individualized goal of what it hoped to achieve with the use of that medication, rather, the goal was that the resident will not exhibit signs of drug related sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms. The facility care planned antipsychotic medications related to anxiety/depression, and at risk for side effects of medication use. She had a [DIAGNOSES REDACTED]. During a brief interview on 02/20/17 at 2:30 p.m., when informed of the lack of individualized care plan goals, the director of nurse was asked to provide any additional information she might have. No further information was provided prior to exit. In an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged the issue of not having individualized goals on the care plan related to [MEDICAL CONDITION] medications.",2020-02-01
4041,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,280,D,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of five (5) residents reviewed for unnecessary medications. Resident #34's care plan was not revised when her antipsychotic medication was discontinued. Resident identifier: #34. Facility census: 61. Findings include: a) Resident #34 Review of the medical record on 02/15/17 found diagnoses, which included [MEDICAL CONDITIONS], depression, and anxiety. Review of medications revealed she formerly received [MEDICATION NAME] (an antipsychotic) 50 milligrams (mg) in the morning and 75 mg at bedtime daily. Review of physician's orders [REDACTED]. During an interview with Registered Nurse #111 and the Director of Nursing (DON) on 02/15/17 at 2:30 p.m., they said she was getting very lethargic on the [MEDICATION NAME] and even wet herself in her sleep without knowing it. They said the physician discontinued the [MEDICATION NAME], and they had to work with the [MEDICATION NAME] in the interim to see how she did. The DON said the resident no longer received [MEDICATION NAME]. Review of the current care plan found one of her care plan interventions included [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 50 mg at bedtime. During a brief interview on 02/20/17 at 2:30 p.m., it was discussed with the DON that the [MEDICATION NAME] was discontinued on 12/26/16, but the care plan was not revised to indicate the medication was discontinued. The current care plan indicated the resident was receiving [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 50 mg at bedtime. She agreed the resident's care plan was not revised accordingly after the medication was discontinued.",2020-02-01
4042,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,282,E,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow the comprehensive care plan for three (3) of five (5) residents reviewed for unnecessary medications. For Residents #34 and #49's the facility failed to implement their care plans directing to utilize nonpharmacological methods to treat behaviors prior to administering medications, and to assess the effectiveness of the as needed (PRN) antianxiety medication. The facility failed to implement Resident #10's care plan directing administration of insulins as ordered by the physician for the [DIAGNOSES REDACTED].#34, #49, and #10. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found [DIAGNOSES REDACTED]. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). The comprehensive care plan review revealed numerous nonpharmacological interventions such as offering a quiet environment, 1:1 (one person to one person), offer fluid/foods, toileting, conversing, activities, observe for pain, and calm approach, before administering the PRN [MEDICATION NAME]. The care plan also directed to monitor the effectiveness of the PRN medications. Review of the medical record found several instances this quarter where the care plan was not followed. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. The nurse progress notes provided no evidence of what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. Also, the medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety. Review of the medical record found no evidence of what if any nonpharmacological methods were attempted prior to giving the PRN medication. - Review of the medical record found a nurse administered a 1 mg dose of PRN [MEDICATION NAME] to this resident on 12/13/16 at 10:20 p.m. Review of the nurse progress notes found no evidence of what, if any, non-pharmacological methods were attempted prior to giving the PRN medication. - Review of the medical record found a administered a 1 mg [MEDICATION NAME] tablet to this resident on 12/16/16 at 9:45 p.m. due to aggression toward staff and hitting staff after she could not be redirected. The medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of PRN [MEDICATION NAME] to this resident on 01/14/17 at 11:43 p.m. Review of the medical record found no evidence of what, if any, nonpharmacological methods were attempted prior to giving the PRN medication. On 02/16/17 at 8:45 a.m., the director of nursing provided what documentation she could find about the resident's behaviors when given [MEDICATION NAME], what nonpharmacological methods were tried prior to giving the [MEDICATION NAME], and assessment of the effectiveness of the PRN [MEDICATION NAME]. On 02/20/17 at 2:30 p.m., a brief discussion with the DON about the issues of not following the care plan to monitor the effectiveness of the PRN [MEDICATION NAME], not following the care plan to attempt nonpharmacological methods to address her behaviors prior to administering the [MEDICATION NAME], and not assessing the medication's effectiveness. There was no evidence staff used nonpharmacological methods prior to administering the PRN [MEDICATION NAME] on 12/07/16, 12/11/16, 12/13/16, and 01/14/17. There was no evidence as to whether the 12/07/16 and the 12/16/16 doses of [MEDICATION NAME] were effective. On 02/22/16 at 1:00 p.m., Registered Nurse #111 said she was unable to find any further evidence. During an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged the resident's care plan was not always followed related to the [MEDICATION NAME] use. b) Resident #49 Medical record review on 02/15/17 found this resident had [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The care plan directed to try nonpharmacological interventions for behaviors such as, but not limited to, activities, interact with her 1:1, exercise, offer food/fluids, and observe for pain. Review of the medical record found this resident received PRN [MEDICATION NAME] on two (2) occasions without evidence that nonpharmacological interventions were attempted prior to giving her PRN [MEDICATION NAME]. A nurse progress note dated 02/07/17 at 3:00 p.m. described the resident was agitated over a band playing music in the solarium. She cursed and talked loudly, so that she had to be removed due to her disruptions. The nurse administered the PRN [MEDICATION NAME] without any evidence of first attempting nonpharmacological methods to help the resident calm. On 02/08/17 at 3:00 p.m., the nurse administered a PRN dose of [MEDICATION NAME] 0.5 mg. for anxiety. Review of the progress note for that time found no description of the type of behaviors she exhibited. There was no evidence the nurse attempted any nonpharmacological methods prior to medicating the resident, nor did the nurse assess the effectiveness of the medication. On 02/20/17 at 2:15 p.m., Registered Nurse #111 printed nurse progress notes for (MONTH) (YEAR) for the two (2) doses of the PRN antianxiety medication. She agreed the nurses did not identify any nonpharmacological methods attempted prior to medicating the resident with the [MEDICATION NAME], and one (1) of the two (2) did not note the effectiveness. During a brief interview with the director of nursing (DON) on 02/20/17 at 2:30 p.m., she was informed of these findings and asked to provide any additional evidence available. No additional information was provided prior to exit. In an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged that nursing staff did not always justify the use of the PRN [MEDICATION NAME]. c) Resident #10 Review of the resident's medical record on 02/21/17 at 1:17 p.m. revealed his [DIAGNOSES REDACTED]. He was ordered blood glucose monitoring twice a day, with scheduled [MEDICATION NAME]90 units to be administered in the morning and scheduled [MEDICATION NAME]80 units to be administered in the evening at bedtime. [MEDICATION NAME]10 units was scheduled to be administered in the morning before breakfast and [MEDICATION NAME]15 units scheduled to be administered in the afternoon before dinner. A pharmacy consultation report issued on 12/07/16 included, Records show on 11/29/16, 12/03/16, 12/04/16, and 12/05/16 no morning [MEDICATION NAME] given. Recommendation: Please educate nursing on importance of proper dosing and [MEDICATION NAME] doses should not be held. Rationale for Recommendation: Basal insulins, such as [MEDICATION NAME] do not affect blood glucose concentrations immediately after administration. The resident's care plan listed a problem of, Resident has Diabetes Mellitus. Potential for episodes of hypo/[MEDICAL CONDITION] (low/high blood sugar). The interventions included, Administer medication as order by MD (medical doctor). The resident's Diabetic Flow Sheet revealed: -- 11/29/16 at 0641 (6:41 a.m.) - blood glucose result of 117, with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) - blood glucose result of 252 (high). -- 12/03/16 at 0600 (6:00 a.m.) - blood glucose result of 259 (high), with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) - blood glucose result of 245 (high). -- 12/04/16 at 0641 (6:41 a.m.) - blood glucose result of 128, with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) - blood glucose result of 243 (high). -- 12/05/16 at 0600 (6:00 a.m.) - blood glucose result of 69, with no morning scheduled [MEDICATION NAME]administered and no physician notification of the medication not given as ordered or of blood glucose level being below 70 as ordered. At 2145 (9:45 p.m.) - blood glucose result of 383 (high). The resident's care plan listed a problem of, Resident has Diabetes Mellitus. Potential for episodes of hypo/[MEDICAL CONDITION] (low/high blood sugar). The Interventions included, Administer medication as order by MD. After reviewing the pharmacy consultation report dated 112/07/16, Diabetic Flow Sheet dated 11/28/16 to 12/07/16 and the resident's care plan on 02/27/17 at 2:10 p.m., the Director of Nursing (DON) agreed the nurse(s) did not administer the scheduled morning insulin for Resident #10 as ordered by the physician. She also verified the nurse did not notify the physician on any of the days the morning insulin was not administered, because absolutely the physician should have been notified on each of those days. The DON stated, I don't know why the nurse held those doses and just glad that he (Resident #10) did not have any complications arising from the insulin being held because he certainly could have had some serious complications. No absolutely the care plan was not followed as far as administering medication as ordered.",2020-02-01
4043,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,319,D,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident interview, and staff interview, the facility failed to ensure that a resident who displayed and/or was diagnosed with [REDACTED]. Resident #29 was admitted to the facility with a history of inpatient and outpatient treatment for [REDACTED]. The primary care physician #181 was notified of her aggressive behaviors and sexual comments on 10/18/16. Despite further notifications, no medication adjustments were made until 01/19/17. In addition, no psychological assessments or behavior management plan was provided when the resident's behaviors towards others increased in (MONTH) (YEAR). This was found for one (1) of one (1) residents reviewed for behaviors. The resident's behaviors had the potential to affect more than a limited number of the resident's fell ow residents. Resident identifier: Resident #29. Facility census: 61. Findings include: a) Resident #29 During an observation of the noon meal service on 02/13/17, Resident #29 was observed attempting to pinch a male nursing assistant's bottom as he escorted her to her table. Random observations on 02/22/17 and 02/23/17, found Resident #29 roaming freely throughout the unit and at times making inappropriate sexual comments to State Surveyors. Resident #29 repeatedly spoke about her desire for sexual relations as well as making comments about her lady parts. Licensed Practical Nurse (LPN) #119 was interviewed on 02/22/17 at 3:46 p.m. and reported Resident #29 was aggressive at times and had to be removed from activities because she makes loud inappropriate sexual comments about men and male visitors. Review of the medical record on 02/28/17 at 9:30 a.m., revealed Resident #29 was admitted to the facility in 2011. Her current [DIAGNOSES REDACTED]. She was independent with most of her activities of daily living and allowed to ambulate independently throughout the first floor of the facility. The nurses' behavior documentation from 09/01/16 through 09/20/16 identified the following behaviors exhibited by Resident #29: -- 09/06/16 - The Director of Nursing (DON) wrote (typed as written): RESIDENT WAS WALKING APAST ANOTHER RESIDENT IN HALLWAY BY NURSES STATION HEARD A LOUD dont do that and she hit resident on arm. she stated resident touched her when she walked by this wasn't witnessed.resident redirected -- 09/11/16 - LPN #171 wrote (typed as written): resident agruing (sic) with another resident redirected becomes upset -- 09/13/16 - LPN #180 wrote: .Resident sexually inappropriate this morning. She stated to this LPN Is this going to give me 8 inches. Am I the only woman in this place looking for sex. I mean, I like dick. Resident redirected . -- 09/14/16 - LPN #171 wrote (typed as written): resident slapping at other resident redirected -- 09/29/17 - LPN #180 wrote: .Resident redirected on several occasions today due to making sexually inappropriate comments . The nurses' behavior documentation from 10/01/16 through 10/31/16 identified the following behaviors exhibited by Resident #29: -- 10/17/16 - LPN #171 wrote (typed as written): sexually inappropriate with males. -- 10/18/16 - The minimum data set (MDS) / Registered Nurse (RN) #111 wrote: Interdisciplinary care plan meeting held .Staff continues to monitor and redirect as needed due to inappropriate comments to male visitors/staff. -- 10/18/16 - LPN #180 wrote: .Resident observed to slap resident (number) across left side of his face as he set down at table for lunch. Resident (#29) began yelling at (Resident number). (Name) Resident #29 was redirected, calmed down and then relocated to her normal table for lunch . Dr. #181 (name) aware. U/A c&s (urinalysis with culture and sensitivity) ordered. -- 10/21/16 - RN #153 wrote in her monthly assessment (typed as written): [AGE] year old female with HX (history): DEPRESSION, .AGGRESSIVE BEHAVIORS SEXUAL TALKING AND TOUCHING AT TIME NOTED .ANXIETY, DEMENTIA, .ambulates independently . The nurses' behavior monitoring documentation from 11/01/16 through 11/30/16 notes the following: -- 11/02/16 - LPN #189 wrote, .Resident states when drinking her prosource I gotta get all the sperm I can from this shot. -- 11/08/16 - RN #111 wrote, Dr. (name of #181) in to see resident concerning the note that he received about resident this past quarter and her physical altercations with other residents - states not going to make medication adjustment at this time but if episodes seem to occur more frequently then he will adjust medications - staff to continue to monitor and intervene if necessary. -- 11/10/16 - LPN #180 wrote, .Resident redirected this morning due to inappropriate sexual conversation attempt with the LPN . -- 11/14/16 - LPN #171 wrote, sexually inappropriate with other residents and staff redirected. -- 11/15/16 - LPN #180 wrote, .Resident relocated away from resident (number) earlier this shift due to verbal aggressiveness toward resident . The nurses' behavior monitoring documentation from 12/01/16 through 12/31/16 identified the following behaviors: --12/18/16 LPN #119 wrote, Resident making inappropriate sexual comments around visitors of other residents. Resident redirected with short success. --12/20/16 LPN #171 wrote (typed as written), redirected from male resident many times she was yelling at him attempting move him away from her table (typed as written). --12/22/16 LPN #119 wrote, Dr. #181(name) made rounds. Orders received for CMP (complete metabolic profile) and fasting lipids. No other orders at this time. The nurses' behavior monitoring documentation from 01/01/17 through 01/31/17 noted the following behaviors: -- 01/05/17 - LPN #171 wrote, resident yelling at other residents redirected becomes angry. -- 01/09/17 - LPN #119 wrote, Inappropriate comments relating to sex made to staff. -- 01/10/17 - LPN #119 wrote, Resident attempted to strike another resident that was invading her space. Resident upset when this nurse told her not to touch the other resident. This nurse asked the resident to speak with her and the resident was angry and said NO and walked away -- 01/13/17 - LPN #119 wrote, SBAR (situation, background, assessment, recommendation) faxed to Dr. (name) in regards to residents increased agitation. Resident has been attempting to hit/push other residents when she feels they are invading her personal space. Resident states that she should be able to defend herself when someone comes to close to her. Possible psych eval (psychiatric evaluation) or medication change requested. -- 01/14/17 - LPN #119 wrote, Resident had completed her lunch and joined in a birthday party for another resident. This nurse had to ask the resident to come to her room d/t (due to) inappropriate behavior w/ (with) visitors. Resident was overheard by staff making suggestive sexual comments, using explicit language, to male visitors while in front of 4 children, ages 5-15 . -- 01/15/17 - LPN #119 wrote, Resident making inappropriate comments to staff about sex. Tells group of ladies at her lunch table that she hopes the ranch dressing tastes like sperm. -- 01/17/17 - The minimum data set (MDS) / Registered Nurse (RN) #111 wrote, Discussed in interdisciplinary careplan meeting .Dr. #181 (name) was notified last week regarding inappropriate comments/more physical aggression and not received a response yet The behavior monitoring nurse's note written by the Minimum Data Set (MDS) nurse on 02/01/17 stated, .Her [MEDICATION NAME] was increased 1/18 for depression and to help deter her sexual inappropriateness - also at times gets physical/verbal with other residents if they are in her space. She is forgetful. Staff continues to monitor and address her needs and try to redirect when she makes inappropriate comments about sex or gets in male visitors space Social Worker #110 stated in her summary on 11/02/16, .up and about daily. She does have some inappropriate talk about sex and men. She is often redirected On 01/18/17, Activities Director #109 wrote in her quarterly progress note, .at times will have some behavior problems, where she is mean with other staff and residents The physician progress notes [REDACTED].Nursing reports [MEDICAL CONDITION] and aggressive behavior, when people enter her personal space Under the Objective heading it stated, .Evaluation does reveal provocative and [MEDICAL CONDITION]. The Impression was, .5. Hypersexual and aggressive behavior. The antidepressant [MEDICATION NAME] was increased to 40 milligrams (mg) daily. The physician's progress note dated 02/16/17 stated under the Subjective heading, .Last month [MEDICATION NAME] was increased to 40 mg daily in hopes of minimizing [MEDICAL CONDITION]. Not very effective. The Impression section included, 4. [MEDICAL CONDITION]. The plan was, Continue medications and supportive care. The most recent psychiatric consult in the record was dated 03/26/14. The physician noted the resident was referred because of her recent inclination to make sexually inappropriate comments to males in her environment. The psychiatrist suggested a trial of [MEDICATION NAME] (antidepressant) for attenuation of her libido and added mood stabilizers may be considered. On 02/28/17 at 3:30 p.m. Resident #29's medical record was reviewed with the Director of Nursing (DON). She acknowledged Resident #29 had a long history of mental illness which included depression, [MEDICAL CONDITION], anxiety, and dementia and she was treated multiple times at a psychiatric facility prior to her admission to long term care. Resident #29's aggressive behaviors towards others and sexual comments increased in (MONTH) (YEAR). The DON acknowledged the primary care physician increased the resident's [MEDICATION NAME] in an attempt to minimize her behaviors and his follow up note on 02/16/17 noted the medication increase was not very effective. The DON confirmed Resident #29 had not had a psychiatric evaluation since 03/26/14 and no other treatment had been implemented to address Resident #29's behaviors. Resident #56 was interviewed on 02/28/17 at 11:20 a.m. She stated Resident #29, has a dirty mouth, and makes inappropriate comments that make me feel uncomfortable. Resident #56 stated she often tells Resident #29 to shut up and go away even though she is not supposed to.",2020-02-01
4044,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,329,E,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's medication regimen was free of unnecessary medications for two (2) of five (5) residents reviewed for unnecessary medications. Residents #34 and #49 received PRN (as needed) antianxiety medication without evidence of nonpharmacological methods attempted prior to the administration of the PRN medication. Nursing administered PRN antianxiety medications without evidence the behaviors warranted the PRN medication. Resident identifiers: #34 and #49. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found diagnoses, which included [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], depression, and anxiety. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. There was no evidence in the nursing progress notes of what behaviors were present at that time, and what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. The medical record was silent as to whether the medication was effective. There was no evidence to support the use of the PRN [MEDICATION NAME]. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety and verbal abuse after nursing staff got her out from behind the nurses' station. There was no evidence of what behaviors were present at the time other than the staff did not want her behind the nurses' desk. There was no evidence of what, if any, nonpharmacological methods were attempted prior to giving the PRN medication. The nurse said only, Resident became verbally abusive with staff on redirection from behind the nurse's station. Then followed a staff aid to the kitchen asking for a cigarette. There was no evidence to support the use of the PRN [MEDICATION NAME]. - Review of the medical record found a nurse administered a 1 mg dose of PRN [MEDICATION NAME] to this resident on 12/13/16 at 10:20 p.m. According to nurse progress notes, the resident ambulated back and forth around the nurses' desk and day area, requesting food and coke, and becoming agitated. The nurse gave the PRN [MEDICATION NAME]. Review of the medical record found no evidence of what, if any, non-pharmacological methods were attempted prior to giving the PRN medication. - Review of the medical record found a nurse administered a 1 mg [MEDICATION NAME] tablet to this resident on 12/16/16 at 9:45 p.m. due to aggression toward staff and hitting staff after she could not be redirected. The medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of PRN [MEDICATION NAME] to this resident on 01/14/17 at 11:43 p.m. Review of the medical record found no evidence of what behaviors were present at that time, or what if any nonpharmacological methods were attempted prior to giving the PRN medication. There was no evidence to support the use of the PRN [MEDICATION NAME]. On 02/16/17 at 8:45 a.m., the director of nursing (DON) provided the documentation she could find regarding the resident's behaviors when given [MEDICATION NAME], what nonpharmacological methods were tried prior to giving the [MEDICATION NAME], and assessment of the effectiveness of the PRN [MEDICATION NAME]. On 02/20/17 at 2:30 p.m., the lack of evidence of behaviors to support the use of the PRN [MEDICATION NAME] was briefly discussed with the DON. There was no evidence that any nonpharmacological methods were attempted prior to administering the 12/07/16, 12/11/16, 12/13/16, and 01/14/17 PRN [MEDICATION NAME]. There was no evidence as to whether the 12/07/16 and the 12/16/16 doses of [MEDICATION NAME] were effective. There was no evidence as to the extent of the behaviors on 12/07/16, and 01/14/17. On 02/22/16 at 1:00 p.m., Registered Nurse #111 said she was unable to find any further information. In an interview with the administrator on 02/28/17 at 3:00 p.m., she acknowledged that nursing staff did not always justify the use of the PRN [MEDICATION NAME]. b) Resident #49 Medical record review on 02/15/17 found this resident had [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the medical record found this resident received PRN [MEDICATION NAME] on two (2) occasions without evidence to support those administrations. A nurse progress note dated 02/07/17 at 3:00 p.m. described the resident was agitated over a band playing music in the solarium. She cursed and talked loudly, so that she had to be removed due to her disruptions. The nurse administered the PRN 0.5 mg [MEDICATION NAME] without any evidence of first attempting nonpharmacological methods to help the resident calm. On 02/08/17 at 3:00 p.m., a nurse administered a PRN dose of [MEDICATION NAME] 0.5 mg for anxiety. Review of the progress note for that time found no description of the type of behaviors she exhibited. There was no evidence any nonpharmacological interventions were attempted prior to medicating her. The nurse did not assess the effectiveness of the medication. On 02/20/17 at 2:15 p.m., Registered Nurse #111 printed nursing progress notes for (MONTH) (YEAR) for the two (2) doses of the PRN antianxiety medication. She agreed the nurses did not show evidence of any nonpharmacological methods attempted prior to medicating the resident with the [MEDICATION NAME] and one of the two did not note the effectiveness. During a brief interview with the director of nursing (DON) on 02/20/17 at 2:30 p.m., she was informed of the administration of PRN [MEDICATION NAME] before first attempting nonpharmacological methods. No further information was provided prior to exit. In an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged that nursing staff did not always justify the use of the PRN [MEDICATION NAME].",2020-02-01
4045,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,353,F,0,1,WA6611,"Based upon family interview, staff interview, review of staffing documentation, review of payroll information, review of incident reports, and review of reports documenting the provision of incontinence care for dependent residents, the facility failed to deploy sufficient qualified nursing staff across all shifts to provide nursing and related services and to ensure resident safety. These findings had the potential to affect all residents residing in the facility. Resident identifiers: #21, #26, #52, and #49 Facility census: 61. Findings include: a) During the survey, complaints regarding staffing were voiced on both of the facility's two (2) units, the second floor unit (Nursing Care Facility Two (NCF2)) and Nursing Care Facility One (NCF1). The units are completely separate. NCF2 currently houses primarily residents who need assistance or are totally dependent on nursing staff for their activities of daily living (ADLs). NCF1 currently houses primarily residents who are more mobile, require less staff assistance with ADLs, but may have dementia, mental illnesses, and behaviors. Because of the unique needs presented on each unit, they were investigated for adequate staffing separately. b) NCF2 1. Two (2) family members voiced concern about inadequate staffing on NCF2 during the early stages of the survey. Interviewee #1 said there were often staffing concerns on day shift. The individual thought there were supposed to be two (2) nurses and three (3) Nurse Aides (NA) on day shift, but usually there were only two (2) NAs, and sometimes only one N[NAME] Interviewee #1 said there were many times when their family member had to wait a long time for needed care, and as a result was sometimes left to sit or lie in their own excrement. Interviewee #1 said the staff tried their best, but they just could not do it with only four (4) staff, let alone with three (3). Lots of the residents needed assistance, some needed the assistance of two (2) staff, and when things got busy, lots of residents waited long time for help. Interviewee #2 also said most of the concern was with day shift. The individual said by early evening most of the residents were in bed, and staff was better able to attend to their needs. Interviewee #2 also said for the most part, the staff did their best to be attentive, but when there were only four (4) in total, or at times three (3), there was no way to meet everybody's needs consistently. 2. Staffing posting sheets and schedules were reviewed beginning on 02/15/17 at 9:30 a.m. The staffing postings, meant to inform residents and visitors of staffing levels throughout the day, rarely matched the schedules and assignments provided for the same day. Administrator #114 had said on 02/20/17 at 2:20 p.m. that almost none of the staffing postings were accurate. For this reason, Administrative Assistant #152 was asked to complete staffing worksheets from payroll records and to correlate that information with the postings and schedules to the extent possible. On 02/20/17 at approximately 2:30 p.m., Administrative Assistant #152 agreed the postings were not reliable. She compiled, and later provided, staffing worksheets that were correlated with payroll records to the extent possible. Administrative Assistant #152 said these records were the most accurate available and they were used for the investigation on both NCF2 and NCF1. Administrative Assistant #152 said sometimes when staffing was short on NCF2, staff were sent downstairs from the acute care hospital unit. This further complicated the ability to identify number of staff. If the staff from the third floor did not change their payroll code by clocking out on third floor and in to second floor, they would not be reflected in the payroll record as having worked on NCF2. The Administrative Assistant said she routinely reviewed the previous day's staffing to make needed corrections when staff from third floor covered NCF2 so her information would be as accurate as possible. Another complication identified was that some of the third floor NAs were registered long term care Nurse Aides and some were not. If third floor sent down a NA that was not registered, that NA could not be permitted to do actual resident care, but was limited to helping out by passing ice, setting up trays, making beds, and so forth. Another complication identified was that third floor staff were never sent to NCF1. When NCF1 needed help, third floor staff were sent to NCF2 and then existing NCF2 staff were sent to NCF1. This was not always able to be identified in the payroll system. 3. Review of the staffing levels on both NCF2 and NCF1 began on 02/21/17 at 8:30 a.m., and continued as days were added to the initial period requested from 01/29/17 to 02/11/17. The final period reviewed was from 01/29/17 to 02/21/17. For NCF2, the review found during that period, the highest day shift nursing staffing was 5.06. The lowest was 2.84. The average was 3.7. There were seven (7) days when the staffing was three (3) or less. There were seventeen (17) days when the staffing was four (4) or less. During those seventeen (17) days, non-certified aides who could not independently provide needed resident care were sent down to assist on 01/29/17, 01/31/17, 02/01/17, and 02/08/17. The census on NCF2 during the survey was twenty-two (22) residents. 4. Nurse #1 said there were usually two (2) nurses and two (2) NAs on NCF2 but not always. When asked if that staffing level was sufficient to meet the needs of the residents, Nurse #1 said, No. Nurse #1 said Look, at the situation here right now. We have twenty-two (22) residents, most need staff assistance for everything. There are two (2) nurses here, both doing medication pass. One NA is giving a bath, the other is transporting a resident downstairs. That leaves no one to answer call lights, provide incontinence care, or to respond to anything else in a timely manner. During an interview on NCF2, Nurse #2 also responded that staffing on NCF2 was not sufficient to meet the residents' needs. Nurse #2 said the nurses had to stop between passing needed medications and leave the medication cart to provide needed care to residents, which they were not supposed to do. Nurse #2 added that when non-certified aides came down from third floor, they really could not do much to help and had to be with a certified aide to even assist with actual care needs. Nurse #2 said sometimes when third floor sent staff to NCF2, NCF2 had to send one of their staff down to NCF1 because third floor staff did not want to go down there. 5. Nurse Aide (NA) #1 said the NAs could not do all the required care when there were only two. The NA said some of the nurses were good to help when needed, but some would not. NA #1 said there were times when he/she was the only NA on the floor, and also said sometimes they sent non-certified aides down to assist and they could not really do anything. 6. On 2/21/17 at 2:30 p.m., information was requested from the Minimum Data Set Assessment (MDS) Coordinator, RN #111 to show how many residents on NCF2 required assistance of, or were dependent, on two (2) or more staff for activities of daily living (ADLs). This information was provided and began to be reviewed on 02/22/17 at 8:56 a.m. The initial review found that of the twenty-two (22) current residents on NCF2: -- Five (5) residents either required the assistance of, or were totally dependent upon, two (2) or more staff for bathing. -- Six (6) either required the assistance of, or were totally dependent upon, two (2) or more staff for dressing. -- Eight (8) either required the assistance of, or were totally dependent upon, two (2) or more staff for toileting. -- Seven (7) either required the assistance of, or were totally dependent upon, two (2) or more staff for transferring, two (2) of which required the use of a mechanical lift and two (2) staff for transfers. When one (1) of these residents required assistance with just one of these ADLs, it would make two (2) caregivers unavailable for other residents during the time required to provide the needed care to the one (1) resident. 7. The ADL of incontinence care was chosen for a more detailed review. Nurse Aide (NA) documentation of when incontinence care was provided in (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) to date was requested for Residents #21 and #26 who were identified by the MDS Coordinator, RN #111 as needing assistance or being dependent for toileting. The facility's ADL documentation was maintained in the electronic medical record (EMR) and required the NAs to login to the medical records program, select their resident, and manually enter the information for each instance of providing incontinence care for each of their assigned residents for their entire shift. Residents #21 and Resident #26 were on a check and change schedule during rounds every two hours. The review found for the period from 12/01/16 to 02/27/17, there was virtually no evidence of toileting being provided every two (2) hours or as needed for either Resident #21 or #26. There were many occasions when no evidence was found that toileting had been done for four to even twenty-four hour intervals. For this reason, the reviews were shortened to include a sampling of some of the most egregious lapses on day shift through the sample period. 8. Resident #21 December (YEAR): -- On 12/03/16, there was no evidence of toileting from 10:52 a.m. to 8:39 p.m., around 9.5 hours. -- On 12/4/16, there was no evidence of toileting from 6:32 a.m. to 4:47 p.m., around 10 hours. -- On 12/7/16, there was no evidence of toileting from 12:21 p.m. to 11:49 p.m., around 11.0 hours. -- On 12/9/16, there was no evidence of toileting from 6:42 a.m. to 1:52 p.m., around 7 hours. -- On 12/10/16, there was no evidence of toileting from 1:56 p.m. to 11:36 p.m., around 9 hours. -- On 12/10/16, there was no evidence of toileting from 5:03 a.m. to 2:25 p.m., around 8.5 hours. -- On 12/12/16, there was no evidence of toileting from 1:28 p.m. to 11:14 p.m., around 10 hours. -- On 12/13/16, there was no evidence of toileting from 1:32 p.m. to 2:05 a.m. the following morning, around 13 hours. -- On 12/14/16, there was no evidence of toileting from 6:05 a.m. to 4:55 p.m., around 10 hours. -- On 12/18/16, there was no evidence of toileting from 7:37 a.m. to 6:53 p.m., around 11 hours. -- On 12/19/16, there was no evidence of toileting from 3:52 a.m. to 8:37 p.m., around 18 hours. -- On 12/3/16, there was no evidence of toileting from 10:52 a.m. to 8:39 p.m., around 9.5 hours. -- On 12/20/16, there was no evidence of toileting from 6:35 a.m. to 9:46 p.m., around 15 hours. -- On 12/21/16, there was no evidence of toileting from 4:00 a.m. to 4:20 a.m. the next day, around 24 hours. -- On 124/3/16, there was no evidence of toileting from 2:06 p.m. to 1:00 a.m. the next day, around 11 hours. -- On 12/26/16, there was no evidence of toileting from 6:57 a.m. to 2:03 p.m., around 7 hours. -- On 12/28/16, there was no evidence of toileting from 3:03 p.m. to 2:25 p.m. the next day, around 23 hours. -- On 12/30/16, there was no evidence of toileting from 11:19 a.m. to 11:01 p.m., around 11 hours. January (YEAR): -- On 01/02/17, there was no evidence of toileting from 7:04 a.m. to 2:25 p.m., around 7.5 hours. -- On 01/03/17, there was no evidence of toileting from 2:25 p.m. the previous day to 10:18 p.m., around 20 hours. -- On 01/06/17, there was no evidence of toileting from 6:57 a.m. to 11:41 p.m., around 17 hours. -- On 01/08/17, there was no evidence of toileting from 6:25 a.m. to 1:21 p.m., and again until 11:42 p.m., the first being around 7 hours, and the second around 10 hours. -- On 01/10/17, there was no evidence of toileting from 10:45 a.m. to 10:00 p.m., around 11 hours. -- On 01/11/17, there was no evidence of toileting from 11:10 a.m. to 1:12 p.m. the next day, around 14 hours. -- On 01/13/17, there was no evidence of toileting from 7:01 a.m. to 3:00 a.m. the next day, around 20 hours. -- On 01/16/17, there was only evidence of toileting at 7:05 a.m. to 1:13 a.m. the next day, around 17 hours. -- On 01/19/17, there was no evidence of toileting from 10:57 p.m. the night before to 2:04 p.m., around 15 hours, and again until 11:50 p.m., around 10 hours. -- On 01/21/17, there was no evidence of toileting from 10:51 p.m. the night before to 2:36 p.m., around 15 hours. -- On 01/22/17, there was no evidence of toileting from 6:23 a.m. to 4:22 p.m., around 10 hours. -- On 01/24/17 and 1/25/17, there was no evidence of toileting from 10:38 a.m. on 1/22 until 9:20 a.m. on 1/23, around 23 hours. -- On 01/27/17, there was no evidence of toileting from 4:09 a.m. to 10:27 p.m., around 18 hours. -- On 01/29/17, there was no evidence of toileting from 6:04 a.m. to 10:59 p.m., around 16 hours. February (YEAR): -- On 02/6/17, there was no evidence of toileting from 6:55 a.m. to 7:32 p.m., around 12 hours. -- On 02/8/17, there was no evidence of toileting from 6:38 a.m. to 10:42 p.m., around 17 hours. -- On 02/9/17, there was no evidence of toileting from 2:19 a.m. to 12:19 a.m. the next night, around 22 hours. -- On 02/11/17, there was no evidence of toileting from 6:48 a.m. to 7:54 p.m., around 12 hours. -- On 02/14/17, there was no evidence of toileting from 7:01 a.m. to 3:28 a.m. the next day, around 20 hours, and again until 3:42 a.m. the next day, around 24 hours. -- On 02/22/17, there was no evidence of toileting from 7:11 a.m. to 3:14 p.m., around 8 hours. -- On 2/26/17, there was no evidence of toileting from 2:30 a.m. to 11:11 a.m., around 8 hours. 9. Resident #26 This resident received Hospice services. She had a care plan that said the Hospice nursing assistant would visit and provide personal care and baths 2 days weekly on Monday and Wednesday. Care would include complete bath/shower with hair care, skin care, mouth care and peri care. To eliminate any doubt regarding toileting, Mondays and Wednesdays were not included in the review. December (YEAR): -- On 12/01/16, there was no evidence of toileting from 6:21 a.m. to 10:54 p.m., around 17 hours. -- On 12/04/16, there was no evidence of toileting from 6:40 a.m. to 2:04 p.m., around 7 hours. -- On 12/10/16, there was no evidence of toileting from 3:05 p.m. to 10:01 p.m., around 7 hours. -- On 12/13/16, there was no evidence of toileting from 1:31 p.m. to 10:45 p.m., around 9 hours. -- On 12/16/16, there was no evidence of toileting from 7:40 a.m. to 1:55 p.m., around 6 hours. -- On 12/17/16, there was no evidence of toileting from 6:28 a.m. to 9:13 p.m., around 16 hours. -- On 12/18/16, there was no evidence of toileting from 7:36 a.m. to 7:51 p.m., around 11 hours. -- On 12/20/16, there was no evidence of toileting from 6:33 a.m. to 9:52 p.m., around 15 hours. -- On 12/23/16, there was no evidence of toileting from 3:02 a.m. to 2:59 p.m., around 12 hours. -- On 12/24/16, there was no evidence of toileting from 2:43 a.m. to 2:50 p.m., around 12 hours. -- On 12/25/16, there was no evidence of toileting from 6:37 a.m. to 2:27 a.m. the next day, around 19 hours. -- On 12/27/16, there was no evidence of toileting from 6:25 a.m. to 10:27 p.m., around 14 hours. -- On 12/30/16, there was no evidence of toileting from 7:00 a.m. to 7:09 a.m. the next day, around 24 hours. January (YEAR): -- On 01/03/17, there was no evidence of toileting from 6:33 a.m. until 1:19 a.m. the next day, around 19 hours. -- On 01/07/17, there was no evidence of toileting from 6:53 a.m. to 11:52 p.m., around 17 hours. -- On 01/08/17, toileting was only documented once, at 7:53 p.m. This would have been around 20 hours from the night before. -- On 01/10/17, there was no evidence of toileting from 6:26 a.m. to 9:17 p.m., around 17 hours. -- On 01/12/17, there was no evidence of toileting from 6:18 a.m. to 10:39 p.m., around 16 hours. -- On 01/13/17, there was no evidence of toileting from 6:55 a.m. to 10:21 p.m., around 16 hours. -- On 01/17/17, there was no evidence of toileting from 10:00 a.m. to 7:46 p.m., around 10 hours. -- On 01/19/17, there was no evidence of toileting from 1:24 a.m. to 2:14 p.m., over 12 hours, and then until 2:00 a.m. the next day, about 12 hours. -- On 01/22/17, there was no evidence of toileting from 6:30 a.m. to 12:03 a.m. the next day, around 17 hours. -- On 01/26/17, there was no evidence of toileting from 11:28 p.m. the night before to 2:26 p.m., around 15 hours. -- On 01/27/17, there was no evidence of toileting from 7:03 a.m. to 10:32 p.m., around 15 hours. -- On 01/28/17, there was no evidence of toileting from 6:28 a.m. to 5:20 p.m., around 11 hours. -- On 01/29/17, there was no evidence of toileting from 6:02 a.m. to 10:56 p.m., around 17 hours. -- On 01/31/17, there was no evidence of toileting from 6:45 a.m. to 11:48 p.m., around 17 hours. February (YEAR): There was no evidence of toileting documented from -- 6:58 a.m. on 02/03/17 until 11:08 a.m. on 02/04/17, around 16 hours. -- On 02/05/17, there was no evidence of toileting from 6:26 a.m. to 3:42 p.m., around 9 hours. -- On 02/09/17, there was no evidence of toileting from 6:51 a.m. to 3:05 p.m., around 8 hours. -- On 02/10/17, there was no evidence of toileting from 6:53 a.m. to 8:43 p.m., around 13 hours. -- On 02/11/17, there was no evidence of toileting from 7:44 a.m. to 9:44 p.m., around 14 hours. -- On 02/15/17, there was no evidence of toileting from 6:52 a.m. to 9:07 p.m., around 14 hours. -- On 02/19/17, there was no evidence of toileting from 6:48 a.m. to 9:58 p.m., around 15 hours. -- On 02/24/17, there was no evidence of toileting from 4:20 a.m. to 2:51 p.m., around 10 hours 10. When asked about the lack of evidence that toileting and peri-care was provided, NA #1 said part of the problem was the cumbersome system the NAs had to use to enter the documentation. All the NAs had varying levels of computer skills. Some could navigate through the steps fairly well, and some just could not do it. This had been brought to the attention of nursing and administration many times, but nothing ever changed. NA #1 said they carried a scrap of paper around with them to jot down when they did the care for each of their residents, which could be 11 or 12 or even more on NCF2 day shift. Then at the end of the shift you have to stay over and try to get all that put in the computer. NA #1 said there had been times when they worked 16 hour shifts on two different units, meaning they would have to then stay over and try to enter documentation on care provided to up to 30 or more residents after working 16 hours straight. NA #1 said for the NA's, it often simply came down to a decision whether to provide needed care or do documentation. The NA said although some care was being provided but not documented, all the needed care was just not consistently getting done. c) NCF1 1. Family Member #3 said their family member tells them they have to wait a long time for care. 2. Review of staffing posting sheets and schedules beginning on 02/15/17 at 9:30 a.m., found the postings, meant to inform residents and visitors of staffing levels throughout the day, rarely matched up with the schedules and assignments provided for the same day. Administrator #114 had said on 02/20/17 at 2:20 p.m. that almost none of the staffing postings were accurate. Administrative Assistant #152 was asked to complete staffing worksheets from payroll records and to correlate that information with the postings and schedules to the extent possible. On 02/20/17 at approximately 2:30 p.m., Administrative Assistant #152 agreed the postings were not reliable, and compiled and provided staffing worksheets that had been correlated to payroll records to the extent possible. Administrative Assistant #152 said these records were the most accurate available and they were used for the investigation on both NCF2 and NCF1. Another complication identified was that third floor staff were never sent to NCF1. When NCF1 needed help, third floor staff were sent to NCF2 and then existing NCF2 staff were sent to NCF1. This was not always able to be identified in the payroll system. 3. Review of the staffing levels on both NCF2 and NCF1 began on 02/21/17 at 8:30 a.m., and continued as days were added to the initial period requested from 01/29/17 to 02/11/17. The final period reviewed was from 01/29/17 to 02/21/17. For NCF1, the review found during that period, the highest evening shift nursing staffing was 8.18. The lowest was 3.5. The average was 5.76. There were five (5) days when the staffing was five (5) or less. The highest night shift staffing was 4.03. The lowest was 2.62. The average was 2.91. There were eighteen (18) days when the staffing was less than three (3). The census on NCF1 during the survey was thirty-nine (39) residents. 4. Nurse #1, initially interviewed on NCF2, said after 7:00 p.m. there were often two (2) aides and one (1) nurse on NCF1. Nurse #1 said with that staffing there was no way to keep track of what was going on. Nurse #2, initially interviewed on NCF2, also responded that after 7:00 p.m. there were often two (2) aides and one (1) nurse on NCF1. Nurse #2 said on NCF1, They (the residents) are all still up at night. The nurse said the residents, .are falling, trying to elope, and wandering into other residents' room and doing things they should not be doing. Observations on 02/22/17 at 8:00 p.m. found the staff posting listed 1 nurse and 4 NAs until 11:00 p.m. Nurse #3 stated there was always one nurse on nights and if there was a problem, you had to prioritize. Nurse #3 said, Bleeding and chest pain comes first. It was acknowledged that after 11:00 p.m., there were 2 NAs scheduled on NCF1. 5. In an interview, NAs #3 and #4 said the staff that night was 1 nurse and 4 NAs until 11:00 p.m. and after 11:00 p.m., there would be 1 nurse and 2 NAs. On the short hall there were five (5) residents who required 2 person assist and on the long hall there were 10 residents who needed two (2) person assist, even though there was only one Hoyer lift on the long hall, the other residents just could not be done with one person. They said there was not enough staff to safely take care of the residents, because, We only have enough time to change them. The aides said they were unable to turn the resident's every two hours or to spend quality time with any of the residents and monitor them. 6. On 02/27/17 at 11:57 a.m., review of incident reports for NCF1 for 01/01/17 to 02/08/17 found for evening and night shift on NCF1 during those 39 days there had been 17 residents found on the floor after apparent falls which staff were not present to observe. There were 3 observed falls. There were 4 altercations or behavior related incidents. In addition to these 24 documented incidents, the survey team discovered and cited as an immediate jeopardy due to 8 incidents of sexual abuse by male residents on NCF1. The action pledged by the facility to abate the immediate jeopardy was the immediate deployment of 3 additional NAs or Nurses to monitor the male residents to adequately protect the other residents. 7. On 02/21/17 at 2:30 p.m., information was requested from the Minimum Data Set Assessment (MDS) Coordinator, RN #111 to show how many residents on NCF1 required assistance of, or were dependent on, two (2) or more staff for activities of daily living (ADLs). This information was provided and a review begun on 02/22/17 at 8:56 a.m. The initial review found that of the 39 residents on the floor: -- 3 residents were totally dependent on 2 or more staff for dressing, -- 5 residents required either assist of, or were dependent upon, 2 or more staff for toileting, and -- 5 residents required either assistance of, or were dependent upon, 2 or more staff for transfers. Of those 5 residents, 4 required a mechanical lift with assist of 2 or more staff for transfers. 8. The ADL of incontinence care was chosen for a more detailed review. Nurse Aide documentation of when incontinence care was provided in (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) to date was requested for Residents #21 and #26 who were identified by the MDS Coordinator, RN #111 as needing assistance or being dependent for toileting. The facility's ADL documentation was maintained in the electronic medical record (EMR) and required the nurse aides to login to the medical records program, select their resident, and manually enter the information for each instance of providing incontinence care for each of their assigned residents for their entire shift. Residents #51 and Resident #49 were on a check and change schedule during rounds every two hours. The review found for the period from 12/1/16 to 2/27/17, there was virtually no evidence of toileting being provided every two hours or as needed for either resident #51 or #49. There were many occasions when no evidence was found that toileting had been done for four to even twenty-four hour intervals. For this reason, the reviews were shortened to include a sampling of some of the most egregious lapses on day shift through the sample period. 9. Resident #51 This resident's care plan included that a Hospice nursing assistant would visit and provide personal care and baths 2 days weekly on Tuesday and Thursday. Care would include a complete bath/shower with hair care, skin care, mouth care and peri care. To eliminate any doubt regarding toileting, Tuesdays and Thursdays were not included in the review. December (YEAR): -- On 12/03/16, there was no evidence of toileting from 6:04 a.m. to 12:23 a.m. the next night, around 14 hours. -- On 12/04/16, there was no evidence of toileting from 6:30 a.m. to 8:19 p.m., around 18 hours. -- On 12/08/16, there was no evidence of toileting from 2:45 a.m. to 10:54 p.m., around 20 hours. -- On 12/11/16, there was no evidence of toileting from 3:15 a.m. to 2:34 p.m., around 11 hours. -- On 12/12/16, there was no evidence of toileting from 2:00 a.m. to 8:42 p.m., around 18 hours. -- On 12/16/16, there was no evidence of toileting from 6:00 a.m. to 3:25 p.m., around 8 hours. -- On 12/17/16, there was no evidence of toileting from 6:20 a.m. until 1:44 a.m. the next day, around 19 hours. -- On 12/18/16, there was no evidence of toileting from 11:41 a.m. to 2:26 a.m. the next day, around 15 hours. -- On 12/21/16, there was no evidence of toileting from 2:42 a.m. to 10:05 p.m., around 19 hours. -- On 12/30/16, there was no evidence of toileting from 10:22 a.m. to 10:24 p.m., around 12 hours. January (YEAR): -- On 01/04/17, there was no evidence of toileting from 6:00 a.m. to 9:21 p.m., around 15 hours. -- On 01/09/17, there was no evidence of toileting from 8:27 a.m. to 6:22 p.m., around 10 hours. -- On 01/10/17, there was no evidence of toileting from 2:53 a.m. to 1:15 p.m., around 10 hours. -- On 01/15/17, there was no evidence of toileting from 1:00 p.m. to 8:50 p.m., around 8 hours. -- On 01/16/17, there was no evidence of toileting from 6:43 a.m. to 7:05 p.m., around 12 hours. -- On 01/18/17, there was no evidence of toileting from 7:45 a.m. to 12:02 a.m. the next day, around 16 hours. -- On 01/22/17, there was no evidence of toileting from 4:52 a.m. to 2:20 p.m., around 10 hours. -- On 01/25/17, there was no evidence of toileting from 6:00 a.m. to 2:34 p.m., around 8.5 hours. -- On 01/30/17, there was no evidence of toileting from 7:45 a.m. to 7:30 p.m., around 12 hours. February (YEAR): -- On 02/01/17, there was no evidence of toileting from 6:42 a.m. to 8:50 p.m., around 13 hours. -- On 02/17/17, there was no evidence of toileting from 6:30 a.m. to 2:02 p.m., around 7.5 hours. -- On 02/21/17, there was no evidence of toileting from 6:30 a.m. to 2:30 p.m., around 8 hours. -- On 02/22/17, there was no evidence of toileting from 4:32 a.m. to 6:25 p.m., around 14 hours. 10. Resident #49: December (YEAR): -- On 12/13/16, there was no evidence of toileting from 4:26 a.m. to 5:00 p.m., about 12.5 hours. -- On 12/17/16, there was no evidence of toileting from 10:14 a.m. to 9:01 p.m., about 11 hours. -- On 12/18/16, there was no evidence of toileting from 6:04 a.m. to 2:02 p.m., about 8 hours. -- On 12/20/16, there was no evidence of toileting from 7:17 a.m. to 3:30 p.m., about 8 hours. -- On 12/25/16, there was no evidence of toileting from 2:00 a.m. to 8:19 p.m., about 13 hours. -- On 12/28/16, there was no evidence of toileting from 6:26 a.m. to 8:19 p.m., about 9 hours. -- On 12/31/16, there was no evidence of toileting from 2:30 a.m. to 10:33 p.m., about 20 hours. January (YEAR): -- On 01/03/17, there was no evidence of toileting from 6:16 a.m. to 2:30 p.m., about 8 hours. -- On 01/04/17, there was no evidence of toileting from 6:43 a.m. to 3:00 p.m., about 8 hours. -- On 01/07/17, there was no evidence of toileting from 7:27 a.m. to 4:30 p.m., about 9 hours. -- On 01/12/17, there was no evidence of toileting from 6:33 a.m. to 7:43 p.m., about 13 hours. -- On 01/03/17, there was no evidence of toileting from 6:16 a.m. to 2:30 p.m., about 8 hours. -- On 01/15/17, there was no evidence of toileting from 7:40 a.m. to 12:44 a.m. the next day, about 17 hours. -- On 01/18/17, there was no evidence of toileting from 7:15 a.m. to 7:08 p.m., about 12 hours. -- On 01/21/17, there was no evidence of toileting from 7:22 a.m. to 8:26 p.m., about 13 hours. -- On 01/22/17, there was no evidence of toileting from 6:51 a.m. to 6:24 p.m., about 12 hours. -- On 01/23/17, there was no evidence of toileting from 4:37 a.m. to 2:29 p.m., about 7 hours. February (YEAR): -- On 02/01/17, there was no evidence of toileting from 5:26 a.m. to 2:42 p.m., about 8 hours. -- On 02/08/17, there was no evidence of toileting from 6:46 a.m. to 4:30 p.m., about 9 hours. -- On 02/12/17, there was no evidence of toileting from 6:54 a.m. to 2:08 p.m., about 7 hours. -- On 02/13/17, there was no evidence of toileting from 2:30 a.m. to 1:45 p.m., about 11 hours. -- On 02/15/17, there was no evidence of toileting from 6:45 a.m. to 4:53 p.m., about 10 hours. -- On 02/20/17, there was no evidence of toileting from 5:53 a.m. to 8:34 p.m., about 14 hours. -- On 02/24/17, there was no evidence of toileting from 9:48 a.m. to 8:00 p.m., about 10 hours. -- On 02/25/17, there was no evidence of toileting from 2:29 p.m. to 11:06 p.m., about 8.5 hours. 11. When asked about the lack of evidence to support that adequate toileting and peri care was being provided, NA #2 described the cumbersome time consuming process the NAs were required to use to document their care. The NA said some NAs were able to get some of the documentation recorded and some were not. NA #2 said even though the difficulty in documenting was a big problem, the care was simply not getting done consistently due to inadequate staffing of NAs on NCF1. 12. Although some of the lack of evidence of care being given might be due in part to limitations of the aides' ability to keep up with the system they are required to utilize for documentation, it was found that on NCF1, the facility reported and substantiated an allegation of neglect on 09/10/16. The 09/10/16 incident substantiated by the facility was that Resident #51 was left in a recliner chair from 5:33 a.m. until 5:30 p.m. During that time, she received no food, no hydration, and was not toileted or repositioned.",2020-02-01
4046,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,356,C,0,1,WA6611,"Based upon observation, staff interview, and review of staffing and payroll documentation, the facility failed to post complete and accurate staffing information. This had the potential to affect all residents and visitors. Facility census: 61. Findings include: a) On 02/13/17 at 11:10 a.m., during the initial tour of the facility, staffing sheets posted for review by residents and visitors were observed on the second floor unit, Nursing Care Facility Two (NCF2). The posting showed the facility name, the date, the shift, the census, and the total hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nurse Aides (NA), but did not show the total number of RNs, LPNs, and NAs working the shift. b) The 02/13/17 posting for the day shift showed there were two (2) nurses and one (1) nurse aide working on the unit. When asked if there was only one (1) NA working the day shift, RN #141 said the posting was not correct, that someone had come down from the third floor to cover and there were two (2). She pulled the posting sheet off the bulletin board and began to correct it. c) Complaints about inadequate staffing on both the second floor unit (NCF2) and the basement unit (NCF1) led to a detailed review of the staff posting, the schedules, and the payroll data for the period from 01/29/17 through 02/21/17. Numerous, almost daily discrepancies were noted between the posting sheets designed to keep residents and visitors informed about how many staff were working each unit and the actual hours reflected in the payroll information provided. d) When questioned about the discrepancies on 02/20/17 at 2:20 p.m., the facility's Administrator, #114, said, Almost none of the staff postings are accurate.",2020-02-01
4047,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,371,E,0,1,WA6611,"Based on observation, staff interview, and facility policy review, the facility failed to prepare and store foods under safe and sanitary conditions. The outside oven doors were soiled, three (3) large storage bins containing sugar, flour, and thick-it sitting next to the oven were coated with grime, and the tile floor in the kitchen cooking area was dirty and stained. In addition, the residents' snack refrigerator contained unlabeled stored foods and a used hot/cold gel pack was stored among the frozen foods. These findings had the potential to affect all residents receiving foods from this central location. Facility census: 61. Findings include: a) Kitchen An initial tour of the kitchen on 02/13/17 at 11:29 a.m. with the Food Service Supervisor, revealed the following: -- the outside of the oven doors were soiled with dirt and running water marks. -- three (3) large storage bins on wheels containing sugar, flour, and thick-it sitting next to the oven/stove were soiled with dried grease and grime along the lower outer sides of the containers. -- the kitchen tile floor in the cooking area was stained and visibly dirty. A follow up observation of the kitchen on 02/22/17 at 8:30 a.m. with the Food Service Supervisor found same observations. The Food Service Supervisor was interviewed at this time and agreed the oven doors were soiled, the outside of the food storage bins located next to the oven/stove were coated with dried grease and grime, and the tile floor around the oven needed scrubbed. Kitchen cleaning schedules for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 1st through the 14th, (YEAR) were reviewed with the Food Service Manager during an interview on 02/22/17 at 8:40 a.m. She acknowledged the cleaning schedules all said at the top of the form, Clean on a weekly basis (daily if needed) and please initial. The Food Service Manager agreed all of the cleaning schedules were incomplete, indicating the kitchen staff did not complete their assigned weekly cleaning duties. b) Snack refrigerator An observation of the residents' snack refrigerator on the first floor, accompanied by the Assistant Director of Nursing (ADON) on 02/13/17 at 12:50 p.m., found the following: 1. The freezer contained: -- One (1) reusable hot/cold gel pack with the yellow charge sticker removed sitting on top of an unlabeled plastic bag containing four (4) slices of pizza. -- a second unlabeled clear plastic bag containing pizza with freezer burn -- an unlabeled McDonald's green shake with an open lid -- an almost empty and unlabeled pint size container of Oreo ice cream The ADON discarded these items during this observation and reported all food items stored in the snack refrigerator were to be labeled and dated when placed in the refrigerator and discarded after seventy-two (72) hours. The Food Storage Safety policy and procedure received from the Food Service Manager on 02/14/17 included, Food or beverages should be labeled with the patient/resident's name and date to be monitored for safety .Foods in unmarked or unlabeled containers are not permitted in the refrigerator/freezer and should be discarded.",2020-02-01
4048,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,428,D,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician responded to a pharmacy recommendation for the gradual dose reduction of an antipsychotic medication in a timely manner. This practice was found for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Resident identifier: #10. Facility census: 61. Findings include: a) Resident #10 On 02/21/17 at 1:17 p.m., medical record review revealed this Resident #10, admitted on [DATE], had [DIAGNOSES REDACTED]. He was currently receiving Risperdal (an antipsychotic medication) 0.25 milligrams (mg) by mouth daily twice a day (BID) for schizoaffective disorder. The pharmacist's consultation report dated 02/03/16 noted the resident was receiving Risperdal 0.25 mg BID. The pharmacist recommended, Please consider a gradual dose reduction (GDR) while monitoring for re-emergence of target and/or withdrawal symptoms. The physician signed the report on 03/08/16 declining the recommendation of a GDR for the antipsychotic medication Risperdal (and provided the rationale for declining the recommendation). The Director of Nursing (DON) signed the report on 03/23/16. After reviewing the pharmacy consultation report on 02/27/17 at 12:40 p.m., the DON stated, I anticipate the GDRs being returned with physician decline or acceptance within two (2) weeks. Absolutely that is not a timely response as you can see it was over a month before he (Physician) filled out the form and longer for him (Physician) to return it to me, of course it is not timely.",2020-02-01
4049,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,431,E,0,1,WA6611,"Based on review of controlled medication sheets, pharmacy reports, staff interview, and policy review, the facility failed to ensure controlled substance records were complete and contained information to show complete reconciliation by on-coming and off-going nurses. This was found for four (4) of four (4) narcotic books (two on nursing home unit 1 and two on nursing home unit 2) reviewed during medication storage. This practice has the potential to affect all residents. Facility census: 61. Findings include: a) Review of the four (4) shift change controlled substance inventory logs dated (MONTH) 27, (YEAR) through (MONTH) 15, (YEAR) on 02/16/17 at 8:45 a.m., found there were seventy-seven (77) blank signature spaces for reconciliation of the controlled medication counts at the change of shifts identified. The Director of Nursing (DON) reviewed the controlled substance logs during an interview on 02/16/17 at 9:28 a.m. She stated, There should not be any blanks for signatures on the narcotic sheets, and yes, there certainly are a lot. A review of the facility's Controlled Substance Policy and Procedure on 02/16/17 at 9:15 a.m. revealed on page 2, titled Procedure C. The change of shift audit will include 1) physical count and reconciliation by the oncoming nurse of the drugs and the Individual Resident's Narcotic Record and 2) inspection of the packaging to ensure integrity. The nurse going off duty shall witness the count and reconciliation. All counts will be documented on a change of shift signature record On 02/16/17 at 9:28 a.m., review of the monthly pharmacy reports for (MONTH) (YEAR) and (MONTH) (YEAR) found the controlled substance logs were not reconciled according to facility procedures and there were irregularities with accurate and complete reconciliation. During a follow-up interview on 02/16/17 at 11:37 a.m., the DON stated, Yes, pharmacy had told me about these irregularities and it also was reviewed in the QA (Quality Assurance) meetings. I had done education with the staff, but evidently, more education is needed. We also need to monitor the narcotic sheets since it is both units and all four of the carts.",2020-02-01
4050,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,441,E,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Residents' briefs and toiletries were improperly stored on the bathroom floor. Dirty plungers were found behind the commodes, and bathrooms were not routinely checked and cleaned as needed. These findings had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #74. Facility census: 61. Findings include: a) Resident rooms 1. An observation of the restroom in room [ROOM NUMBER] on 02/13/17 at 2:53 p.m., revealed -- a package of briefs on the floor next to the commode -- bottles of shampoo, moisturizer, body wash, and lotion sitting on the floor between the toilet and shower. 2. The restroom in room [ROOM NUMBER], observed at 3:00 p.m. on 02/19/17, had: -- a plunger in an open plastic bag behind the toilet -- an open bag of briefs stored on the floor next to the garbage can. Registered Nurse #116 viewed the restrooms in rooms [ROOM NUMBERS] during an interview on 02/13/17 at 3:41 p.m. She reported storing briefs and toiletries on the restroom floor and leaving a plunger in the bathroom were infection control issues. Staff should be making rounds and checking the residents' rooms. 3. An observation of room [ROOM NUMBER] on 02/13/17 at 3:02 p.m. revealed: -- a soiled brief on the floor to the right of the toilet and a pair of pants on the floor on the left side of the toilet. A follow up observation of the restroom in room [ROOM NUMBER] on 02/14/17 at 9:48 a.m., revealed: -- a soiled brief and pair of sweat pants with visible stool on the floor by the commode. -- Remnants of stool were on the bathroom floor in front of the toilet where the resident's feet would rest when sitting on the commode. -- During a follow up observation of room [ROOM NUMBER] with the Assistant Director of Nursing (ADON) at 2:00 p.m. on 02/14/17, she confirmed there was stool on the floor in front of the commode along with a soiled brief and pair of soiled pants. The ADON reported the nurse aides did not make rounds and check the restrooms for cleanliness. The aides should have checked the room and notified housekeeping. Housekeepers #28 and #58, interviewed on 02/14/17 at 2:15 p.m., reported they started cleaning in room [ROOM NUMBER] every morning and moved throughout the department cleaning each residents' room. They did not return to a resident's room unless the staff notified them.",2020-02-01
4051,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,463,D,0,1,WA6611,"Based on observation and staff interview, the facility failed to ensure all portions of the call light system were functioning. The call light system for two (2) resident bathrooms did not light up in the hallway above the doors to the rooms to alert staff of the residents' need for assistance. This was found for two (2) of thirty-five (35) resident bathrooms. Room numbers: #29 and #2. Facility census: 61. Findings include: a) Observations of the facility during Stage 1 of the Quality Indicator Survey revealed two (2) rooms did not have adequately functioning bathroom call light systems to allow residents to call for assistance. -- Room #29 On 02/14/17 at 3:00 p.m. during a bathroom observation, when the bathroom call light was pulled it sounded and lit up at the nurses' station, but did not light up above the resident's room to alert staff of the location. The Nursing Home Administrator (NHA) was present during this observation and verified the bathroom call light did not light up above the resident's door. The NHA commented maintenance would be notified to repair the light over the resident's door immediately. -- Room #2 At 4:39 p.m. on 02/14/17 observation found when the bathroom call light was activated, it sounded and lit up at the nurses' station, but did not light up above the resident's room to alert staff of the location. Registered Nurse #141 verified the bathroom call light did not light up above the resident's door. She said maintenance would be notified to repair the light over the resident's door.",2020-02-01
4052,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,468,E,0,1,WA6611,"Based on observation and staff interview, the facility failed to maintain the corridors on the long hall and short hall on nursing home unit 1 with firmly secured handrails on each side of the corridors. Multiple handrails in the corridors utilized by residents in the main thoroughfares were discovered to be loose and/or pulled out of the wall when grabbed/pulled by hand or used as support to assist with locomotion. This had the potential to affect more than an isolated number of residents residing on nursing home Unit 1 who require assistance and/or were dependent with locomotion. Facility census: 61. Findings include: a) Short hall on nursing home Unit 1 The corridor handrail was loose and not secured to the wall on either side outside of: -- Room #2, -- Room #4, and -- Room #6. b) Long hall on nursing home Unit 1 The corridor handrail was loose and not secured to the wall on either side outside of: -- Room #32. -- Room #33, and -- Room #40, and actually came loose from the wall exposing a hole and the bolt used to anchor the handrail to the wall. -- The corridor handrail outside of the Pantry room door was missing an end piece exposing a sharp jagged edge on the remaining center handrail piece. -- The corridor handrail outside of the dining/solarium/activity room had a two (2) inch by two (2) inch hole with a depth of three and a half (3-1/2) inches on the wall on the underside of the handrail where an anchor bolt was removed and placed further up on the handrail. c) At the conclusion of the tour, accompanied by Nursing Home Administrator #114, Maintenance Supervisor #42, and Housekeeping Supervisor #91 on 02/15/17 between 2:40 p.m. to 3:05 p.m., all agreed the observed problems needed repaired and/or replaced. When asked whether they were aware of the issues, Maintenance Supervisor #42 stated, Yes, I tour here every day and see this every day, but no repairs have been done.",2020-02-01
4053,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,490,F,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, resident interviews, family interviews, confidential interviews, staff interviews, record review, review of staffing and payroll information, policy review, review of facility documents, and record review, the facility was not being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to notify residents' responsible party and or physician of incidents, failed to identify occurrences and protect residents from sexual abuse, failed to report occurrences of abuse and neglect to required State agencies, failed to ensure a safe environment, failed to ensure residents received appropriate care for pressure ulcers, and failed to provide sufficient staff across all units and shifts to meet the needs of residents. These finding had the potential to affect all residents living in the facility. Facility census: 61. Findings include: a) The facility failed to notify residents' responsible parties and/or physician of incidents of resident-to-resident sexual abuse, failed to identify incidents of sexual abuse and protect the subjects of the abuse, and failed to report incidents of abuse and neglect to required agencies. Medical record reviews, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, found the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse, and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids, and provided no incontinence care. The following incidents were found to have not been reported to the residents' responsible parties and/or physician, not reported to required State agencies, and staff failed to identify nonconsensual sexual contact and implement effective interventions. 1. Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. 2. Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. 3. Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. 4. Alleged Perpetrators: a. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b. Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c. Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents d) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. e) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. f) Resident #24 (TRUNCATED)",2020-02-01
4054,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,514,E,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, confidential interviews, and policy review, the facility failed to maintain complete, accurately documented clinical records of each resident. Staff failed to accurately monitor and document Resident #75's, Resident #74's, and Resident #33's pressure ulcers, to include depth, any exudate (wound drainage) and a description of the pressure ulcer including surrounding tissue. Resident #74's medical record also contained an incorrect discharge date documented on the form used to document pressure ulcers. In addition, residents' medical records lacked documentation of incidents of sexual abuse. This practice had the potential to affect all residents residing in the facility. Resident identifiers: #75, #74, #33, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #75 Review of the medical record on 02/15/17 at 9:07 a.m. found Resident #75, admitted on [DATE], had [DIAGNOSES REDACTED]. He was discharged from the facility to home on 01/18/17. The wound/pressure ulcer forms lacked documentation of any measurement of wound depth if present, exudate, description of the wound bed and surrounding tissue. -- On 12/27/17, the wound/pressure ulcer size was documented as 1 cm (centimeter) x (by) 1 cm -- On 01/02/17, the wound/pressure ulcer size was documented as 0.25 cm round -- On 01/9/17, the wound/pressure ulcer size was documented as not open -- On 01/16/17 the wound/pressure ulcer size was documented as not open The column titled Eschar/Necrotic was blank. The column titled site was documented on each of the previous dates as L (left) buttock. Also, a handwritten discharge date of [DATE] was documented on the form, when the resident was discharged from the facility on 01/18/17. After reviewing the wound/pressure ulcer forms for Resident #75 on 02/15/17 at 9:00 a.m., the Assistant Director of Nursing (ADON)/Wound Nurse #112 stated, No the form does not show an accurate measurement of the wound which should include depth or a zero for no depth. No it does not describe what the wound looks like. I just used these forms and did not make any adjustments, not sure if these are hospital forms or not. On 02/15/17 at 10:12 a.m., after reviewing the wound sheets for Resident #75, the Director of Nursing (DON) stated, No it definitely is not a complete and accurate wound sheet, it does not even describe the wound and depth is always part of the wound measurement. The discharge date should always be correct on the wound sheet and this discharge date is not even close to being correct. c) Resident #74 Review of the medical record on 02/16/17 at 8:12 a.m., revealed Resident #74 was admitted to the facility with Stage II pressure ulcers on both elbows and a Stage I pressure ulcer on his coccyx. The resident developed pressure ulcers on his buttocks, heel and toes after admission on 12/19/16. The nursing physical assessment admission note dated 12/19/16 stated Left elbow Stage II wound 3 centimeter (CM) circle with hole in middle open purple with serious serioussangus (sic) drainage noted. Right elbow 3 cm round hole 1.25 depth with brownish/tan drainage noted. Buttocks with old red scar right proximal. The records were silent in regards to any further wound assessments until 12/30/16. --On 12/30/16 the Assistant Director of Nursing (ADON)/wound care nurse documented a wound assessment in the computerized progress notes. bilateral elbows were a stage 2 on admission - now are resolving and only has some redness around perimeter . The handwritten wound form provided by the ADON on 02/16/16, identifies the Stage II pressure ulcers on the elbows present on admission but lacks information related to tunneling, odor, wound edges, and pain. --On 01/09/17 the ADON/wound nurse documented an assessment in the computerized notes stating: Bilateral elbows were noted to have stage 2 pressure ulcers on admission - areas are now dry and slightly red area - continue to use skin prep bilaterally BID (twice a day) [MEDICATION NAME]. No assessment was found on the hand written wound form to correlate with this assessment. --On 01/16/17 the ADON/wound nurse wrote in the computerized progress notes, right elbow - slightly pink - open area 0.50 cm round and 0.25 deep - using skin prep - added elbow protectors resident has tendency to lean to right and puts pressure on elbow - very bony all over . The handwritten wound form stated, right elbow 0.5 open hole area. Left elbow ___0.5 scab area Both are checked as Stage II pressure ulcers. There is no information related to odor, tunneling, wound edges, surrounding tissue or discomfort. --On 01/25/17 at 2:02 p.m. the ADON/wound nurse documented in the computerized progress notes: a (left elbow per pressure ulcer/location unisex body form) - resolving stage 2 - 4 cm round dk (dark) purple - not open - skin prep and elbow protectors. b (right elbow per pressure ulcer/location unisex body form) resolving stage 2 - 4 cm round dk (dark) purple with open area - 0.10 deep - skin prep - elbow protectors. There was no information related to odor, tunneling, wound edges, surrounding tissue or discomfort. --On 01/26/17, the Director of Nursing (DON) documented the wound assessment in the section titled Pressure Ulcer Condition: Rt (right) buttocks with 2 open areas red periwound with yellow center. Lt (left) buttocks with 1 open area red periwound with pink center. Rt heel with DTI (deep tissue injury) skin intact. Rt great toe posterior (top) pinpoint open area. All areas no odor noted. Under the section titled Pressure Ulcer Stage, the DON documented: --A - RT buttocks 0.5 x 0.25 cm Stage 2. --B - RT buttocks 0.25 cm x --C - LT buttocks 0.25 cm x --RT heel - DTI 1 cm x 1 cm unstagable. --RT Great toe pinpoint area Stage 2. --On 02/06/17, the DON documented a wound assessment evaluation in the computerized records: she wrote: --A - RT (right) buttock with open area pink center no drainage, 0.25 cm x 0.25 cm x 0,25 cm Stage 2 --B - RT buttock no open area pink in color, 0.25 circular area superficial D/I (dry and intact) pink in color Stage 2 --C - LT buttock no open area pink in color, superficial D/I (dry and intact) pink in color Stage 2 areas with healthy tissue --D - RT heel DTI intact area drying 1 cm x 1 cm edges intact --E - RT great toe pinpoint scabbed area posterior UTD (unable to determine) edges intact unable to determine --F- RT elbow --G - LT elbow superficial area pink in color skin intact resolved Stage 2 The wound care notes were reviewed with the ADON/wound nurse during an interview on 02/16/17 at 9:30 a.m. She reported she had no education or training in wound care, nor did she have a mentor she could contact with questions. She acknowledged her wound form tracking sheets were confusing and incomplete. The section titled Date facility acquired is blank or is marked for the day she completed the assessments. The wound sheets lacked complete measurements, exudates, and a description of the wound and surrounding tissues. The Director of Nursing (DON) reviewed the medical record during and interview at 9:45 a.m. on 02/16/17. She agreed the wound records were incomplete. Weekly wound assessments were not documented and assessments lacked complete descriptions of the wounds, including full measurements, tunneling, drainage, odor, wound edges, surrounding tissue, and pain. The facility policy titled Preventing Pressure Ulcers with a revision date of 12/23/2010, states under #4 of the procedure section: For any resident that is determined to have a Stage I pressure ulcer or higher, a Registered Nurse will document a weekly assessment . Resident #74 was admitted with pressure ulcers to his elbows and a Stage I sacral pressure ulcer. Weekly skin and wound assessments were not conducted and the inexperienced wound nurse's assessments lacked descriptive information of the wound and surrounding areas. Also, a handwritten discharge date of [DATE] was documented on the form, when the resident was discharged from the facility on 01/18/17. c) Resident #33 On 2/15/17 at 9:03 a.m., during a review of Resident #33, a wound assessment form competed on 01/20/17 by Registered Nurse #105 indicated a pressure ulcer for Resident #33 had worsened, but the pressure ulcer records were incomplete. They lacked a full description of the wound including size, tunneling, odor, wound edges, exudate type, amount and consistency, wound edges, wound pain, and description of surrounding tissue. d) Resident #39 The following incidents of sexual abuse were found in the alleged perpetrator's (Resident #10) medical record, but nothing was found in Resident #39's medical record: - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurses notes stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurses notes for stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. - A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.) Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. - On 02/01/17 at 6:42 p.m. - a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. No evidence was found of documentation of any of these incident's in Resident #39's medical record. In an interview with the Director of Nursing (DON), on 02/22/17 at 2:06 p.m., the DON agreed the incidents of sexual abuse should have been documented in Resident #39's medical record. e) Resident #26 The following incidents of sexual abuse were recorded in the alleged perpetrator's (Resident #62) medical record, but were not reflected in Resident #26's medical record: On 10/06/17 at 10:06 a.m., in nursing notes Resident #62 found reaching for the crotch of Resident #26. Again at 18:47 (6:47 p.m.) found Resident #62 reaching for the crotch of Resident #26 and residents were separated and continued to follow. No evidence was found in Resident #26's medical record of this event. In an interview with the Director of Nursing (DON), on 02/22/17 at 2:06 p.m., the DON agreed the incidents of sexual abuse should have been documented in Resident #39's medical record. f) Resident #51 Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she has seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informs the nurse whenever this occurs. An incident report was reviewed dated 12/08/16. According to the incident report, Resident #51 sat in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt and fondled her breasts and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. Review of the nurse progress reports found no documentation about this 12/08/16 incident between the two (2) residents, nor of notification of the responsible party, nor of notification of the physician. Review of the medical record on 02/28/17 found the medical record was silent for reports that she was inappropriately touched by male residents. g) Resident #49 Confidential interviews were obtained with CI#1, CI#2, CI#6, CI#10, and CI#11 in separate interviews. All five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheels his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she has heard handicapped Resident #49 holler, then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 has touched Resident #49 inappropriately over her clothing. She said she reports inappropriate touching to the nurse in charge whenever it occurs. CI#10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by male residents. h) Resident #24 CI #11 said that once over a month ago she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by certain male residents. i) Resident #37 CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by certain male residents. j) Resident #1 CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub Resident #1 on her legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. She said she reported this to the nurse in charge at the time. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by a male resident. The DON agreed there was an absence of documentation in the nurse progress notes related to these episodes of inappropriate touching.",2020-02-01