| 10742 |
HERITAGE CENTER |
515060 |
101-13TH STREET |
HUNTINGTON |
WV |
25701 |
2011-08-25 |
166 |
E |
1 |
0 |
36XK11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's grievance / complaint reports, family interview, resident interview, and staff interview, the facility failed to make prompt efforts resolve grievances. There was no evidence of a thorough investigation into grievances filed by (or on behalf of) two (2) of six (6) sampled residents and four (4) random residents identified through a review of twenty-two (22) grievance reports reviewed. Resident identifiers: #136, #7, #158, #106, #24, #31, and #137. Facility census: 154. Findings include: a) Resident #136 Review of grievance / complaint reports found a report filed by a family member dated 07/05/11, stating (quoted as written): "Daughter reported concerns of the resident in the room next to her mother and her screaming all of the time. ..." Under the heading "Documentation of Facility Follow-up", and in response to the question "What other action was taken to resolve this concern (be specific)?", the author wrote: "Informed (name of family member filing complaint) we were working /c (with) (name of Resident #155) & collaboration /c Admin, DON (director of nursing),Soc Serv & myself." Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form checked "Yes" and noted (quoted as written): "... 3) (name of family member filing complaint) was advised of above re (regarding) (name of Resident #155)." The author also noted she had a one-to-one conversation with the persona filing the complaint about this resolution on 07/08/11. An interview was conducted with the family member on 08/24/11 at 2:00 p.m., she stated the grievance regarding the resident in the next room (#155) was still an issue, that there had been no resolution of this issue, and that the residents in the vicinity of the room of this resident were complaining. According to the family member, this has been an on-going unresolved issued for the past six (6) weeks. In an interview on 08/25/11 at 11:00 a.m., the director of nursing (DON) and the unit manager reported the facility had implemented measures to address Resident #155's screaming, but nothing seems to work. They stated they could not discuss the specific measures with the family member, but they agreed this grievance has not been resolved. This interview also revealed the facility had not conducted any investigation to see whether the noise level associated with Resident #155's screaming was uncomfortable / disruptive to other residents in the vicinity (beyond Resident #136). Although the above note grievance / complaint report was marked to indicate the concern was resolved, it was, in fact, not resolved and present ongoing concerns to Resident #136. -- b) Resident #7 Review of grievance / complaint reports found a report filed by a family member dated 08/05/11, stating this resident was missing two (2) gowns and some white plastic hangers with the resident's name on them. Under the heading "Documentation of Facility Follow-up", the unit manager and housekeeping supervisor were identified as the persons designated to take action on this concern. All of the other sections of the form under follow-up were blank. There were no details of what action(s) was (were) taken to resolve the concern. Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form did not check either "Yes" or "No". All that was written in this section was: "Facility was searched, laundry staff interviewed. Unable to locate the clothing. Will see if the facility will replace." There was no evidence to reflect the resident or representative was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing items. -- c) Resident #158 Review of grievance / complaint reports found a report filed by a family member dated 08/04/11, stating she was missing a pair of pants with small brown checks, a pair of yellow Capri pants, and a pullover sweater with short sleeves. Under the heading "Documentation of Facility Follow-up", the housekeeping supervisor was identified as the person assigned to take action on this concern on 08/05/11, and the concern was to be resolved by 08/12/11. Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form did not check either "Yes" or "No". All that was written in this section was: "Facility was searched, unable to locate missing items. Will see if the facility will replace." There was no evidence to reflect the resident or representative was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing items. -- d) Resident #106 Review of grievance / complaint reports found a report filed by the resident dated 07/27/11, stating: "She stated she does (symbol for 'not') get her things back from laundry. When they bring her clothes back, they just put them anywhere. Other peoples clothes are put in different closets." Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form checked "Yes" and noted (quoted as written): "Had a new girl working in laundry and she was putting the clothes in the wrong closets other laundry aids sorting them out. This documentation provided an explanation as to what happened, but there was no indication as to whether the facility actually found the resident's missing clothes. -- e) Resident #24 Review of grievance / complaint reports found a report filed by a family member dated 07/06/11, stating a cup containing six (6) rings ("good costume jewelry") at her bedside that missing since 07/01/11. Under the heading "Documentation of Facility Follow-up", no individual staff member had been designated as responsible for taking action on this concern; instead, the author of the report noted (quoted as written): "Asked Staff to watch for these Items." The date this action was assigned was 07/06/11, and the date to be resoled was 07/07/11. Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form did not check either "Yes" or "No". All that was written in this section was: "Rings have (symbol for 'not') been located." During an interview with Resident #24 on 08/25/11 at 2:00 p.m., she stated they never did find her rings. She stated she knew she put them in a cup on her bedside table before she went to sleep. When asked if the facility ever got back with her about the rings, she said she had never heard anything since she reported them missing. -- f) Resident #31 Review of grievance / complaint reports found a report filed by the resident dated 06/09/11, stating she was missing a black hoodie. Under the heading "Documentation of Facility Follow-up", the unit manager and "ESD" (environmental services director) were identified as the persons designated to take action on this concern, with the concern assigned on 06/09/11 and the date to be resolved identified as 06/16/11. In response to the question "What other action was taken to resolve this concern (be specific)?", the author wrote: "Checked with laundry." Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form checked "Yes" and noted (quoted as written): "Facility was searched, unable to locate hoodie. Will see if facility will replace." There was no evidence to reflect the resident was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing item. -- g) Resident #137 During an interview with Resident #137, he informed this surveyor that he was not able to find his Kindle (brand-name of a wireless electronic reading device or "E-reader"). He stated it has been missing since 08/11/11; he reported the missing E-reader to staff a couple weeks ago, but staff still hasn't found it. He stated he fell asleep and he had it in his bed. When he woke up, they changed his sheets, and he thought that maybe it got wrapped up in his sheets. He stated he has checked with the laundry, and they have not found it. He stated he called the police today (08/24/11) and reported it. Resident #137 stated the device cost him over a hundred dollars and he had about fifty (50) books on it that he had bought. He had the two (2) nursing assistants on duty that night to look for it. He stated another nursing assistant came in at shift change, and he helped look. The nursing assistants were aware of the missing electronic device, but they did not report it to the nurse to pursue an investigation. - Review of the facility's grievance / complaint reports for the past three (3) months found no report recording the resident's complaint regarding the missing E-reader. The administrator was questioned about this at 4:15 p.m. on 08/24/11. He stated he would ask the nurses on the unit if they had the complaint form, because they are the ones who do them. On 08/25/11, a copy was provided of a grievance / complaint report dated 08/15/11, which recorded the following concern (quoted as written): "Reports Loss of E-Reader the last of last wk." Under the heading "Documentation of Facility Follow-up", "All Departments" were identified as the persons designated to take action on this concern, with the concern assigned on 08/15/11 and the date to be resolved identified as 08/26/11. In response to the question "What other action was taken to resolve this concern (be specific)?", the author noted (quoted as written): "Questioned (name of resident) if he could have left this somewhere out of Facility. He reports was out of case laying in his room - when he last saw it." The author also noted all departments were notified, all second floor staff was notified and all department managers were to be notified in the morning. Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form checked "No" and wrote: "Unable to find missing E-Reader. 8/24 - (Name of resident) filed a report /c (with) Hunt. ([MEDICAL CONDITION]) Police Dept." There was no written investigation, nor were statements obtained from staff about the missing E-reader. The information the resident reported to this surveyor (about the device being in his bed when he last saw it and then being gone when he woke up), which he had also told the nursing assistants the night the device went missing, was not included in the grievance / complaint report. During an interview with Employee #157 (a nursing assistant) on 08/24/11 at 5:30 p.m., he said he looked for the device and verified the resident reported it missing on 08/11/11. When asked to whom he had reported the resident's complaint about the missing device, he said everyone knew about it and all of the nurses knew. He stated he has picked things up out of the resident's trash can beside his bed many times, where he drops items, and he thinks he may have dropped it in the trash. Employee #175 verified that, when the resident reported this missing, he said had it in bed with him at that time. The administrator, when subsequently interviewed about the facility's practice of replacing missing items, stated that sometimes they do if the family buys something new; they just bring in a receipt. He said that, if the residents have the missing items on their inventory lists, he will replace them, but they do not replace everything that comes up missing. He was not sure if they kept records of what they replaced and the reasons why they chose not to replace certain items. There was no records of these actions provided to the surveyor at the conclusion of this survey on 08/25/11. . |
2014-12-01 |