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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3079 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2019-11-04 | 600 | K | 0 | 1 | MFEO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, incident report review, resident interview, and staff interview, the facility failed to ensure residents were free from verbal, psychological and physical abuse when confronted with resident to resident altercations. This practice caused actual harm to Resident #307 and #5. Resident #307 experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by crying shaking, and showing signs of sadness. Resident #5 was experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by expressing feealings of fear and being unsafe. The actual harm and immediate jeopardy was further evident by the fact the facility did not report, investigate, nor put protections in place to safeguard residents from Resident #8, who had exhibited numerous incidents of verbal, mental and physical aggression towards residents and staff. The Centers for Medicare and Medicaid Services determined this deficient practice was an immediate jeopardy. State Agency surveyors notified the facility administrator of the immediate jeopardy on 11/04/19 at 12:32 PM. The facility abatement plan was approved through verification of implementation on 11/04/19 at 4:50 PM. The facility's abatement plan included: 1. Resident # 8 no longer resides in the facility. Resident #s 5, 2, 13, 22, and 45 were seen by facility Nurse Practitioner on 10/14/2019 to evaluate residents for emotional and psychological harm. Resident #s 5, 2, 13, 22, and 45 have not experienced any negative outcomes. On 11/1/2019 Resident #5 denied concerns, anxiety, fear related to any additional residents in the facility. Resident # 307 no longer resides in the facility. 2. All residents of the facility have the potential to be affected. On 10/16/19 all incident reports and resident council minutes from 04/01/2019 to current were audited by the Administrator to ensure all potential incidents of abuse, including resident to resident altercations, were thoroughly investigated, reported to the appropriate state agencies, and that protective safeguards were put into place to protect residents from the verbal, mental, and physically aggression of other residents. The Social Worker/designee will interview interviewable residents and the Director of Nursing/designees will conduct body audits of non-interviewable residents by 11/07/2019 to ensure other residents are free from verbal, psychological, and physical abuse when confronted by resident to resident altercations. No other residents are exhibiting verbal, mental, and physical aggression towards residents or staff. 3. By 11/07/2019 all facility staff, including contracted and agency will receive abuse prohibition reeducation by the Director of Social Services/ designee to ensure all residents are 1) free from abuse including verbal, psychological, and physical abuse, 2) that timely reporting to appropriate state agencies occurs, 3) a thorough investigation is conducted, 4) involved residents' reactions are assessed and 5) interventions/safeguards are initiated to protect the residents when confronted by resident to resident altercations, with a post-test to validate understanding. Facility staff, including contracted and agency staff not available during this time frame will receive reeducation including a post-test by the Director of Nurses/designee upon day of return to work. New facility staff, including contracted and agency staff will be provided education with a posttest to validate understanding during orientation by the Director of Nurses/designee. Starting 10/30/2019 all incident reports and resident council minutes will be reviewed by the Administrator/designee and 10% of residents will be interviewed daily including weekends X 2 weeks, then 3X week X 2 weeks, then randomly thereafter to ensure all residents are free from verbal, psychological, and physical abuse when confronted by resident to resident altercations; ensuring timely reporting to the appropriate state agencies, a thorough investigation is completed, involved residents' reactions are assessed and that interventions are initiated to protect involved residents with immediate corrective action. 4. Results of these audits will be reported by the Administrator /designee monthly to the QAPI committee for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QAPI committee. Upon verification of the implementation of the facility abatement plan, the deficient practice was reduced to a D. Resident identifiers: #307, #2, #5, #13, #45, , #8. Facility census: 62. Findings included: a) Findings for 11/04/19 Interviews with [NAME] residents were conducted on (MONTH) 4, 2019. Residents were asked about their overall feelings in the facility, specifically, if they feel safe. Below are the replies: At 1:55 PM, Resident #5 stated she had been afraid of another resident, who is no longer in the facility. She was referring to resident #8. Resident #5 added that she was verbally abused by resident #8, in the past. She added that she is glad he is out of the facility. Resident #5 did report that resident #45 has threatened her. This was resolved when resident #5 reported this to nursing staff. Resident #5 reported that she feels safe in the facility. At 2:06 PM, Resident #13 was unable to answer questions. She was pleasantly confused and began discussing her birthday, company housing, her husband's death and her six children. At 2:19 PM, Resident #22 stated she is safe. Resident #22 reported resident #8 threw coffee during Bingo, at one point. She added that nothing like that has happened, since. Resident #22 is glad that resident #8 is no longer in the facility. Resident #22 reported Resident #45 has referred to her as a [***] . She does not feel threatened or abused. At 2:28 PM, Resident #2 stated she feels safer without Resident #8 in the facility. She added that when she has reported issues to nursing staff, they assist. At 2:35 PM, Resident #45 was unable to answer questions. She was confused and appeared agitated. During her continual chatting, she said she was happy and sad. She added that she writes books and it is how you are raised. Abuse training has begun for Staff. [NAME] Administrator plans to have all staff trained by (MONTH) 7, 2019. On (MONTH) 4, 2019, several staff members were interviewed, regarding. Below are their replies: At 3:30 PM, Employee #12, Activities Director, reported that the facility has done a lot of education regarding abuse. Employee #12 stated she has been trained to protect the residents, first, if there is an abusive situation. Employee #12 identified step two is to contact her supervisor, regarding the situation. Employee #12 has handled abusive situations with this protocol. Employee #12 added that she would call OHFLAC, if necessary. At 3:40 PM, Employee #84, Licensed Practical Nurse, stated she has not been working for the past few days. She stated that she would report an abusive situation to her supervisor. According to [NAME] Center's inservice sign in sheet, regarding Abuse Policy, Employee #84 has not been trained, as the signature line is empty. At 3:45 PM, Employee #59, Nursing Assistant, reported she has received the inservice. Employee #59 stated she would stop the abusive behavior, initially. She would follow up by reporting to her supervisor. Employee #15, Nursing Assistant, was interviewed with #59. She also had the inservice. She reported she would stop the abuse, then report it to her supervisor. At 3:50 PM, Employee #15, from the Maintenance Department, acknowledged that he has been trained. Employee #15 stated that he would stop the abusive situation and then report it to his supervisor. He added that he would report to OHFLAC, if nobody else was available to report. An employee from the Laundry Department, was interviewed at 3:55. Employee #86 stated she would report the situation to her supervisor. Employee #86 added that she would not get in the middle of that. There is no evidence that Employee #86 has received the Abuse Policy inservice. Employee #72, Clerk, acknowledged the inservice. At 4:00 PM, Employee #72 reported she would try to stop the abuse and report to a nurse. At 4:05, Registered Nurses #82 and #52, stated they would protect the residents, first. #82 stated she would then report to OHFLAC, Adult Protective Services and the Ombudsman. #52, would report to her supervisor and complete a change in condition. At 4:09 PM, Employee #8 from Physical Therapy, stated the most important thing is to protect the residents. That is what Employee #8 would do, before notifying supervisor. At 4:15 PM, Dietary employees #34 and #20 reported they would protect the residents and follow up with notifying supervisor. Employee #34 would then follow up with OHFLAC. At 4:40 PM, DON was made aware of complaints regarding Resident #45. She is aware of issues with this resident. She added that Resident #45 had a Urinary Tract Infection and was treated. In addition, resident #45 had [MEDICATION NAME] discontinued through a gradual dose reduction. They have evaluated the resident and believe she would benefit from [MEDICATION NAME], at her maintenance dosage. DON added that they will be obtaining orders to begin giving her [MEDICATION NAME]. b) Policy and Procedure Review A review of the facility policy and procedure titled WV Abuse Prohibition with effective date of 06/01/96, review date of 10/10/16 and revision date of 11/28/16 was conducted. The policy stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to their supervisor immediately. Additionally, the incident is to be reported to OHFLAC (Office of Health Facilities and Certification), APS (Adult Protective Services), and the Ombudsman. If the resident sustains serious bodily injury, the Nursing Home Administrator (NHA) or designee is to be notified and reported within two (2) hours. c) Resident #307 On 10/08/19 at 11:00 AM, a review of an incident report dated 05/18/19 at 6:50 PM stated that Resident #307 was sitting in the common area in front of the Nurses Station. When Resident #8 started yelling racial slurs and calling him (Resident #307) vulgar names. Resident #307 started shaking and crying asking, Why is he call me names? I didn't do anything to him. I don't like to be called names and I don't like to be hollered at. What did I do to him to talk to me like that? Resident #307 was removed from the situation and consoled. The incident report noted resident-to-resident-NO ABUSE. Injury Psych (psychological), harm. An additional incident on 05/19/19 at 14:40 (2:40 PM) Resident #307 was in the common area when another resident (Resident #8) from the adjoining TV room started yelling and cursing and calling him N*****. Resident #307 started crying and expressing feelings of sadness and repeatedly stating why does he say that to me and why does he call me names? What did I do for him to talk to me like that. Resident #307 was harmed by showing signs of emotional distress of crying and being cursed and insulting name calling. d) Resident #2 In an interview with Resident #2 on 10/08/19 at 12:17 PM revealed she had observed Resident #8 yell, cuss and scream at other residents. Resident #2 stated other residents had told her without revealing other residents names, that they were afraid of Resident #8. Resident #2 stated she had seen Resident #8 go after other residents and had stepped in to protect other residents. She stated she is not afraid of Resident #8. e) Resident #5 A review of incident report dated 10/07/19 5:30 PM revealed Resident #5 was confronted by Resident #8 who was sitting on the table next to her. Resident #8 wanted the TV on. Resident #5 stated that the TV was only for Bingo. Resident #8 continued to argue with the other resident who then raised fists at Resident #5 and moved closer. Resident #8 continued to yell at Resident #8 raising fists while staff tried to pulled Resident #8 away. Resident #5 continued to yell and stated that if you hit me you will go to prison. During the Resident Council meeting on 10/08/19 at 2:30 PM Resident #5 stated that Resident #8 continually curses at her and calls her names. Resident #5 stated she does not feel safe and Resident #8 scares her. f) Resident #13 A review of the incident report dated 04/29/19 at 3:30 PM revealed Resident #8 was in dining room and began to yell and scream and threw his glasses, cards and a plastic flower vase which hit Resident #13 in the right side of face. Both residents were removed from the dining room for safety. No injury noted to Resident #13. A nurses note dated 04/30/19 Resident #13 has stayed away from Resident #8. g) Resident #45 A review of incident report dated 10/05/19 at 10:15 PM, Resident #8 was sitting at table coloring in common area. Resident #45 rolled over to the common area and started pecking Resident #8 on the shoulder. Resident #8 turned around and hit R#45 multiple witnessed times with closed fist before staff could separate them. Resident #45 removed from situation and placed in a safe environment while the aggressor #8 continued to pursue other unidentified residents and staff members. The incident report indicated there was no injury. No evidence was found as to the emotional status of this resident after the altercation. No further evidence was presented prior to exiting the facility as to this resident emotional status. h) Resident #8 An incident report on 09/14/19 at 6:14 PM review found the Director of Nursing (DON) was called to the dining room where Resident #8 was yelling and screaming. He was served his food and had asked for a salt and pepper shaker. The aide in the dining room handed him the shakers and he immediately stated to scream that he wanted the glass shakers. He became mad and threw the shakers at the aide leaving a mark on her arm. He continued to yell at residens and staff. The DON told him that he could not eat in the dining room as he was scaring residents. The Dietary Manager (DM) told him that she would serve his meal at the table in the TV lounge. He then grabbed a knife and a fork (plastic) and moved to the table fist raised utensils in his hand. He then moved to the DON and tried to stab with the utensils. The DON told him that he was not able to eat in the dining room in this state and she asked him to leave. In the meantime the DM had called the police. He continued to scream and yell until the police came and continued to call the officer names. The police officers called EMT (Emergency Medical Team) to see if any intervention was possible. Resident #8's guardian came in and talked to the officers. The Guardian stated she would like to have him evaluated by psychiatry. EMT could not take him in and the police officers left. Corrective actions noted on the incident report were to observe closely, try to remove from any triggers that start aggressive behavior. An interview with the DON on 10/08/19 at 3:25 PM found that no investigation of the incidents, witness statements, how other residents and victims were protected from this resident. The DON confirmed they did not follow their policy and procedure to report, investigate and assess resident reactions when the residents were involved and/or were victims of the abuse. The DON stated it would require another person just to notify other agencies and to conduct the investigations. | 2020-09-01 |