cms_WV: 10997
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10997 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 223 | G | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to ensure residents were free from abuse. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others (beyond Resident #12), and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and "X". Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and "X" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - "Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone." (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - "Employee was alleged to have squirted water on resident (#62). ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that employee tied resident's (#30) wheelchair to side rail. ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that employee encouraged resident (#61) to yell and cuss. ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that this employee placed cold water on the resident's face (#62). ..." (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that this employee was verbally inappropriate to residents." (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that the employee put resident (#60) to bed in a rough manner. ..." (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..." (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents." (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - "It was alleged that employee used inappropriate restraints (on Resident #30)." (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - "It was alleged that employee used inappropriate restraints (on Resident #12)." (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): "This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds." In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: "Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..." - In a statement dated 01/22/10 by Employee #50 (a CNA): "I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..." In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: "I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)" - In a statement dated 01/22/10 by Employee #58 (an LPN): "This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents "rowled" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them." - In a statement dated 01/23/10 by Employee #73 (an LPN): "I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..." In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: "Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything." In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: "... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..." - In a statement dated 01/23/10 by Employee #59 (an LPN): "I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)." In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: "...Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..." - In a statement dated 01/23/10 by Employee #51 (an LPN): "I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..." In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: "... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..." In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: "... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..." - In a statement dated 01/23/10 by Employee #76 (a CNA): "I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated." - In a statement dated 01/23/10 by Employee #5 (a CNA): "I have only heard by another CNA that Nurses was getting a Resident upset." - In a statement dated 01/23/10 by Employee #79 (a CNA): "I am aware of no misconduct in this facility over 6 months ago. I was asked to change out oxygen parts by midnight shift." - In a statement dated 01/25/10 by Employee #75 (a CNA): "(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react." In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: "I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..." In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: "... (Employee #81) encourages (Resident #12's first name) to cuss." - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: "... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say." -- 3. Failure to Meet Reporting Requirements Although the witness statements did not identify when each of these alleged events occurred, it was evident that these events were not immediately reported after they occurred by the employees to the facility's administrator as required by this regulation. Additionally, the earliest statements containing allegations of resident abuse / neglect by Employee #81 were dated 01/22/10, but the first self-report of an allegation of abuse was not sent to the State survey agency until 01/25/10. The initial reporting of allegations of abuse / neglect against Employee #81 were not made within no more than twenty-four (24) hours after they were received by the facility as required by this regulation. Furthermore, not all of the events alleged by the employees in their witness statements were reported to the State survey agency as required by this regulation, including the following allegations: - Employee #81 pinched Resident #12's nose to get her to take medications, food, and fluids - Employee #81 poured cold water on Resident #59 to get her to quiet down - Employee #81 initialed residents' medical records to indicate medications were administered when they were not given - Employee #81 allowed unqualified non-licensed personnel to perform tasks outside of their "scope of practice", such as administer medications / treatments, perform invasive procedures (to include giving fingersticks and insulin injections), etc. - Employee #81 tied garbage bags around Resident #12 and Resident "X" to keep them from falling -- Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - A review of Resident #12's medical record revealed she have a [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. The director of nursing and the registered nurse consultant, when interviewed on the afternoon of 06/09/11, agreed the medical record contained no documentation regarding why Employee #81 digitally removed stool from Resident #12. - Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 physical discomfort and/or emotional distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. (See also citation at F225.) - Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected three (3) residents to involuntary seclusion by restraining them with inappropriate devices in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy titled "Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation" (effective 01/09/09). (See also citations at F225 and F226.) . | 2014-10-01 |