cms_WV: 3312
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3312 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 607 | E | 0 | 1 | KGJN12 | Based on record review, policy review and staff interview the facility failed to implement their Abuse Policy as it pertained to the reporting and investigating of allegations of abuse. This practice has the potential to effect all residents currently residing in the facility. Resident #13 on multiple occasions was sexually abusive toward six (6) different female residents. These allegations were not reported and/or investigated thoroughly as directed by the facility's policy. Resident identifiers: #13, #55, #40, #2, #25, #61 and #15. Facility census: 56 Findings Include: a) Resident #13 A review of the reportable incidents from 05/29/19 through current found an Immediate Fax Reporting of allegations - Nursing Home Program. This form was completed by the facility's social worker on 06/04/19 and faxed to the Office Health Facility Licensure and Certification (OHFLAC) on 06/04/19 at 1:25 p.m. The date of the incident was listed as 06/03/19 and the brief description of the incident read as follows, (First and Last name of Resident #13), resident at the (Name of facility), approached 3 female residents trying to rub his private area against them and put his penis in their mouth. Staff immediately intervened and diffused the situation. Review of the Five Day follow up form found the following under the section titled outcome/results of investigation: (First and Last name of Resident #13), resident at the (Name of Nursing Facility) approached 3 female resident trying to rub private area against them and put his penis in their mouth. Staff intervened immediately and diffused the situations. Families were notified of the incident. Under the section Corrective Action by the facility the following was noted, (First and Last name of Resident #13) was sent out of facility for psychiatric treatment/evaluation. Addressed behavior in care plan to avoid any further incidences. Resident will be assessed upon return for mental status and any further behaviors. A review of the investigation or this incident found only one statement from a staff member attached. This statement was from the receptionist who works in Human Resources Employee #54 about an incident which took place on 06/04/19 at 7:23 a.m. it read as follows, I was buzzed into the building and went to clock in. When I rounded the corner after clocking in, I saw Mr. (Last name of Resident #13) grabbing (First Initial and last name of Resident #55)'s wheel chair and turning it to face him. He then stood up, reached his hand down his elastic panty and showed Ms. (Last name of Resident #55) his penis. I said very firmly Stop. Mr. (Last name of Resident #13) only laughed. I told Mr. (Last name of Resident #13) I don't think it's funny at all to which he responded. I think it's real funny! and continued to laugh. Ms. (Last name of Resident #55) had wheeled away from him by then and I went down the hall to immediately report what I had seen to the [MI]P.N. (Licensed Practical Nurse) at the desk (First and last name of LPN #7). (First and last name of LPN #91) contacted my office a few minutes later and asked me to write a statement. This statement was in regards to an incident that happened 06/04/19 which was not the incident that was reported for 06/03/19. No other statements were attached to this investigation. An interview with the NHA at 1:36 p.m. on 07/23/19 confirmed the statement attached to this investigation was for a different incident and there were no other statements attached and/or obtained in regards to the incident on 06/03/19. A review of Resident #13's medical record at 1:00 p.m. on 07/22/19 found the following pertinent nursing progress notes, -This note was entered as a late entry for a date of 06/03/19 at 4:35 p.m. (Recorded as Late Entry on 06/04/2019 11:41 AM) resident has been wandering up and down hallways and in and out of dining hall. sexually inappropriate behaviors x 3 noted by staff and residents. resident was noted to remove his penis from his pants and rubbing it on another res., face, also putting it in 2 residents mouth. he was approached quickly and re directed away from residents, and q 15 minutes watch was started. This note was written by LPN #82. -06/04/19 at 7:49 a.m. Resident was noted by (First Name of Employee #54) in HR to be exposing himself to a female resident. Resident was walked back to his room by staff. Notified (First and Last name of administrator), Administrator. Resident is to be transported to (Name of local hospital) for evaluation. MPOA notified and was in agreement. (Name of local rescue Squad) called for transport at 0739. Report called to (Name of local hospital) at 0739. VS 128/72 Temp 98.0 HR 78 Resp 18 O2 Sat 98% BRS arrived 0748. Resident transported out of facility at 0755 accompanied by 2 attendants. Please note a statement was not obtained from LPN #82 regarding this incident even though she must have had knowledge of what had happened. Also the nurses note clearly identify four (4) separate occurrences of sexual abuse. Three (3) on 06/03/19 which were reported on 06/04/19 outside of the required two (2) hour time frame and one (1) on 06/04/19 which was not reported at all. -06/19/19 at 12:46 p.m. Resident observed by staff displaying sexually inappropriate behaviors. Q15 minute checks initiated to monitor Resident. -06/20/19 at 4:47 p.m. Resident was walking back from dining room down short hall. CNA reported resident smacked her buttocks as he walked past. Q 15 minute checks in place. Will continue to monitor and observe. -06/20/19 at 5:53 p.m. Resident being transferred to (Name of Local hospital) via (Name of local rescue squad) for evaluation for admittance to (Name of Local Psychiatric Hospital). Resident has been noted by staff to be exhibiting inappropriate sexual behaviors to other residents and staff. (Name of local rescue squad) called at 1736. MPOA (First and last name of MPOA) called at 1737. No answer received. Message left informing of Resident's transfer and instructions to call facility with any questions. Report called to (First name of RN at local hospital), RN at (name of local hospital) ER at 1742. Behavioral observation completed. Transfer/Bed hold form completed and will be sent with resident in transfer packet. -06/28/19 at 12:30 p.m. Resident returned to facility at 1220 via (Name of local Rescue Squad) x 2 attendants. No complaints voiced. No signs symptoms distress noted. Resident shown to new room in (Room Number Redacted for confidently). Resident expressed understanding. VS BP 94/61 HR 68 Temp 98.4 Resp 18 O2 Sats 97%. Skin Assessment performed. Resident cooperative and agreeable. Will continue to monitor. -06/28/19 at 1:30 p.m. Resident observed by staff members exhibiting inappropriate sexual behaviors with other residents in residents room and dayroom. Staff intervened. RN notified. Resident being monitored closely at this time. -06/28/19 at 3:05 p.m. New order received to transfer resident as a direct admit to the (Name of Local Psychiatric Unit). Q 15 minute checks initiated. MPOA (first and last name of MPOA) notified and expressed understanding and agreement. (Name of local rescue squad) called for transport. Report called to (First and Last name of RN at local hospital), RN. (Name of local rescue squad) arrived 1507. VS 94/61 Temp 98.4 Resp 18 HR 68 Resident left facility by stretcher via (Name of local Rescue squad) x 3 attendants at 1507. At 2:00 p.m. on 07/22/19 the Nursing Home Administrator (NHA) was interviewed. When asked if the incident that took place on 06/19/19 and 06/28/19 were reported she indicated they had not been reported. She stated, We reported the first incident, but since he is confused and the victims were confused and they had sent him out they did not think the other incidents were reportable and did not report them. She stated, The residents did not know what was going on so we did not think we needed to report the additional incidents. At 2:20 p.m. on 07/22/19 the Social Worker joined the interview with the NHA, they were asked what the nursing note dated 06/19/19 was referring to. The note was not clear as to who the sexual inappropriate behaviors exhibited by Resident #13 on this date were directed toward. The Social Worker indicated it was Resident #25. When asked what Resident #13 had done to Resident #25 on this date the social worker stated, I think she told me he had just pulled his Junk (Junk is a slang term for a males penis and testicles) out. The social worker stated, I did a concern form about it but did not report it. A review of the concern forms found a form dated 06/20/19 which was completed by the Social Worker. The form was concerning Resident #25 and under the section titled, Describe grievance/compliant using factual terms: the following was hand written by the Social Worker, Resident Stated male resident was being sexually inappropriate (touched her face with penis). This was a one time occurrence. Male Resident is very confused. Under the section title, What other actions were taken to resolve grievance/compliant (be specific)? 15 minute checks were initiated; Resident is encouraged to stay in common areas of facility so staff can monitor the situation male resident was sent out of the facility for an evaluation on 06/21/19. The record also contained no further information regarding the incident on 06/28/19. There was no concern form completed nor a reportable and the victims for this incident were not identified prior to surveyor intervention. During a final Interview with the NHA and Social Worker at 1:36 p.m. on 07/23/19 the above findings were reviewed. The NHA stated we can see now that maybe we did not do enough. We thought that sending him out to the hospital would be enough but now we see that we did not do enough to keep the other residents safe. She agreed the incident on 06/03/19 though it was reported was not thoroughly investigated and the incidents on 06/04/19, 06/19/19 and 06/28/19 were not reported and/or thoroughly investigated. b) Policy Review A review of the facility's policy found the following pertinent information: . Definition of Abuse .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Implementation of Abuse policy and procedures 5. Investigation: All different types of incidents and complaints will be screened for possible sign of abuse. The complaint coordinator will be responsible Igor the initial reporting, investigation of alleged violations, and reporting results to the proper authorities . 7. Reporting/Response: All alleged violations and substantiated incidents will be reported to the state agency and to all other agencies as required, and depending on the results of the investigation, necessary corrective actions will be taken. The facility will report to the state nurse aide registry or licensing authorities any knowledge it has of any actions )by a court of law which would indicate and employee is unfit for service. The occurrences will be analyzed to determine what changed are needed, if any to policies and procedures to prevent further occurrences. | 2020-09-01 |