| 3715 |
LAKIN HOSPITAL |
5.1e+125 |
1 BATEMAN CIRCLE |
WEST COLUMBIA |
WV |
25287 |
2019-09-12 |
600 |
E |
0 |
1 |
K00K11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to ensure Resident's #21, #22, #11 and #66 were free from psychological and verbal abuse. The facility failed to prevent Resident #51 from wandering into other resident's rooms/space; cursing at others; taking, touching, and rummaging through other resident's personal property thus evoking resident to resident altercations, evoking fear and unrest among other residents. This was true for five (5) of six (6) residents reviewed for resident to resident altercations. Resident identifiers: #51, #22, #66, #21, and #11. Facility census: 75. Findings included: a) Resident #51 Review of the resident's most recent Minimum Data Set (MDS) with an assessment reference date of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days. b) Observation of Resident #51 behaviors During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. The following are observations on the day of entrance to the facility. --09/09/19 12:53 PM, R 51 wandering around A wing. --09/09/19 12:56 PM, R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM, Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 1:07, R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There was no staff supervision during these observations. --09/09/19 1:08 PM, R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM, R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM, R #51 went back into Room A-1. Employee #22, LPN, was present A North Hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 1:11 PM, R #51 entered Room A-2. R #51 and was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 1:12 PM, Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LP, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM, Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM, Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 pm. --09/09/19 01:19 PM, R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM, Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM, Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM, Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM, Resident #51 was cursing another resident (Resident #1). This occurred in the hallway at the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM, Resident #51 entered Room A-11. --09/09/19 04:15 PM, Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. c) Nursing notes found in Resident #51's medical record. A record review of Resident #51 noted the following nurses notes (copied as written in resident's chart) --6/2/19 at 15:46: Resident cont. (continued) to be restless and agitated this shift. PRN ( as needed) [MEDICATION NAME] given per order with minimal effect. Resident has been going into resident #9180 room causing that resident to become agitated. Multiple attempts at redirection, but behavior cont. throughout this shift. Placed on cb for physician review charge nurse notified of prn [MEDICATION NAME] and resident change in behavior, notified POA/family [NAME] of residents change in behavior. Family noted to increase in agitation, as they attempted an outing with resident when she became extremely agitated and attempted to bite daughter. Pre restraint form completed. --6/3/19 at 20:00: Resident receives prn [MEDICATION NAME] having agitation, yelling very loud in dayroom as staff attempts to redirect her from going in other resident's rooms, she refuses snacks and drinks as staff attempts to change her mood with snack or drink, resident spills pop on her bed leaving the near full can on her blankets. --6/5/19 at 00:02: Resident receives her prn [MEDICATION NAME] for agitation as she has been offered snacks and drinks to shift her mood, while she was in the bathroom, she removed her depends, torn up depends but into the three bathroom sinks and turned the water on, staff has returned her to her bed several times since 10:30 pm and hopefully she will be able to get some rest having received her prn. --6/5/19 at 01:32: Resident up out of bed, ambulates to bathroom on A North, spends a little time in the bathroom, water could be heard running, staff goes to the bathroom to find all three sinks with paper towels and toilet paper in the sink with the water running strong and water overflowing into the floor, one toilet plugged up also, night shift staff clean up bathroom, resident currently in room lying on bed as if asleep. --6/5/19 at 21:41: Resident agitated, shouting at staff. PRN [MEDICATION NAME] given at 730 pm. Is currently asleep in her bed. --6/6/19 at 12:25: Night shift charge nurse reported concerns about (name of resident) and her recent worsening of behaviors, her increase incidents of behaviors, such as wandering, taking items from others, screaming at staff, making false accusations, plugging up the toilet and sink, tearing dressing off her arm. (Psychiatric Physician name) ask us to consult with (Attending Physician name), and to do medical work up such as labs and ua. Notified (attending physician) of the above concerns and he plans to see (resident) on his visit tomorrow. --6/8/19 at 20:00: Resident receives prn [MEDICATION NAME] for aggression, as we were unable to change her mood by offering snacks, drinks or restroom needs, she had returned to the bathroom and was found with wet towels in the sink and the water running, she has been pacing and can be heard repeating herself, she speaks hateful when staff attempts to move her away from the bathroom sink or away from another resident as she stands in their personal space. --6/9/19 at 20:20: Resident receives pen [MEDICATION NAME] for aggression, she can be heard talking hateful as staff attempts to redirect her away from other residents, she is not concerned with a snack or drink this writer offers a drink and she will say 'I don't want it', she had been following staff into other resident's room as staff is assisting other resident's to bed, she stands in the doorway talking to herself, when staff asks her to leave or the resident of the room asks her to leave she becomes hateful in her response by the time staff walks her out of the room she is fitful and returns to the same place as if she intends to do what she wants. --6/11/19 at 06:31: Resident given PRN [MEDICATION NAME] at HS for agitation. Rsdt (Resident) walking very quickly down the halls, clenching fists and yelling, 'I'm leaving, I'm leaving.' Slept through night and woke up at appx 5 am and picked off scabbed areas on lower R (right) arm. Areas cleaned and dry dressings applied and also covered with long sleeve. --6/11/19 at 23:00: Resident received prn [MEDICATION NAME] for aggression, being unable to calm self, uncooperative to accept sandwich or drink, she has been yelling very loud paces hallways is returned to unit per staff and continues to be loud. --6/15/19 at 11:40: Resident given PRN [MEDICATION NAME] 1mg d/t increased agitation; and [MEDICATION NAME] 50 mg, Tylenol 650 mg po d/t increased pain. Resident increased pacing and crying at this time. Resident having moments of yelling. --6/17/19 at 20:00: Resident receives prn [MEDICATION NAME] for anxiety as drinks and snacks does not seem to help improve her mood, she continues to pace, repeat herself and speaks of leaving. --6/20/19 at 20:15: Resident received prn [MEDICATION NAME] for agitation, staff unable to improve her mood with drinks or snacks, she is loud at intervals repeats herself, paces and argumentative. --6/21/19 at 06:17: Resident agitated this evening, yelling at staff, stating that she wants to leave, walking very quickly up and down the halls. Unable to redirect with snack. PRN [MEDICATION NAME] given at 8pm. --6/22/19 at 06:04: Resident very agitated, picking at scabs on her arm and saying she wants to 'get out of here and never coming back.' Attempts to redirect her with a snack and juice are unsuccessful. PRN [MEDICATION NAME] given per MD order. --7/4/19 at 09:08: Resident ambulating in hallway, agitated. yelling at staff. Uncooperative with care. Multiple attempts at Redirection unsuccessful. Prn med given with success. --7/5/19 at 20:46: HSW (health services worker) stated that resident has been turning on all the sinks, yelling at residents in the hallway, saying, 'it hurts, I've got to get out of here!' Unable to redirect her. Gave her a PRN [MEDICATION NAME] for her agitation . --7/9/19 at 10:00: Resident was getting into trash and other resident's belongings. Pacing back and forth. Redirection unsuccessful. [MEDICATION NAME] 1mg po given per order. --7/11/19 at 20:00: Received prn [MEDICATION NAME] for anxiety, after receiving a drink, snack, and encouraged to sit down, but continued pacing and yelling. --7/12/19 at 10:44: Resident pacing and yelling. Drinks and food offered with no success. PRN [MEDICATION NAME] given as ordered. --7/15/19 at 20:15: Resident had got into the big trash can on the unit and got a diaper out of it and rubbed her face with it getting BM on her nose and cheek. Hsw cleaned it off and redirected resident to stay out of the trash can. --7/15/19 at 20:30: Resident receives prn [MEDICATION NAME] for agitation after receiving snacks and a drink and being unable to improve her mood, she has been unable to verbally redirect as she paces the unit, goes in and out of other resident's rooms, she picked up a blanket belonging to another resident becomes more loud and argumentative when verbally redirected to return items, other residents become upset which has caused loud outburst on unit, she removes several pairs of depends off the cart, takes gloves out of the boxes on the wall, tears on the occupied sign that is on the staff's restroom door. --7/16/19 at 10:22: Resident was becoming more agitated, getting into other resident's belongings. Got resident # 9120 remote. Very uncooperative. [MEDICATION NAME] 1mg po given. --7/17/19 at 01:45: Resident had been asleep earlier but is now awake, assisted to bathroom, assisted back to bed but up gotten up self up out of bed and walking unit, going into other resident's rooms, becomes argumentative when verbally redirected by staff, encouraged to sit in chair on hall and would only sit for a brief period of time, received drink and snack but did not improve her mood, received [MEDICATION NAME] PRN PO (by mouth) for agitation. --7/17/19 at 20:15: Receives PRN PO [MEDICATION NAME] for agitation after resident's mood is unchanged by being offered snacks, drink, urged to sit down, or lay down, she has been pacing hallway and going into other resident's rooms. Some residents fuss at her to leave the room she then becomes loud, has a frown and stomps as she walks and talks as if angry, 'I'm leaving here, I'm not coming back' she repeats this phrase and as she continues this behavior. --7/19/19 06:27: Resident was given PRN [MEDICATION NAME] at HS d/t her behaviors. She was agitated, pacing the floor, yelling at others. Unable to distract resident by offering a snack or a drink. Took medications without incident. --7/21/19 at 20:00: Med prn for anxiety et pain. Pacing et worried expression. (et means and) --7/23/19 at 06:40: PRN [MEDICATION NAME] administered at 730pm, d/t resident being agitated, yelling at other residents, shouting, 'I have to leave!' Resident went to sleep appx 830 pm and slept well without further incident. --7/24/19 at 06:42: Resident was repeating, 'it hurts, it hurts. She was walking very quickly into other resident rooms, getting into the trash can in the hallway, turning on the sinks in the bathroom. Unable to distract rsdt with juice or snacks and wouldn't sit in the recliner. Administered PRN [MEDICATION NAME] for her agitation . --7/25/19 at 21:19: Resident was screaming at HSWs that were trying to calm her down, asking her to sit in the chair. HSW ( health service worker) reported that for the past few hours, rsdt has been going into the bathroom and turning on the sinks; digging in the trash, going into others rooms and messing with others belongings and picking at her arms. At 8pm, this nurse administered a PRN [MEDICATION NAME] to her, per MD order. --7/26/19 at 00:53: Resident awoke at approx 2400. She is very irritable, screaming at the HSW and running down the hall. She continuously entered bedrooms that weren't' her own, sitting on top of resident who were sleeping. Tried to redirect with a drink and a snack, but resident became louder and angrier. Administered a PRN [MEDICATION NAME] per MD order at this time --7/29/19 at 00:02: Resident pulling dirty briefs out of the trash. She is very upset, yelling at HSW, 'I've got to go, get out, get out!' Unable to redirect to recliner. Offered snack, but declined. Administered PRN [MEDICATION NAME] per MD order at this time. --7/30/19 at 16:30: This resident was getting anxious, pacing back and forth and going into other residents rooms. Redirection unsuccessful, would just get more agitated. [MEDICATION NAME] 1mg po given per order. 7/31/19 at 08:09: Resident ambulating up and down hallway. In and out of other resident rooms. screaming 'it hurts' Redirection unsuccessful. Prn [MEDICATION NAME] and anxiety med given with success. --8/3/19 at 06:51: Resident ambulating on the unit, yelling out, 'It hurts, it hurts.' --8/4/19 at 18:05: Resident was screaming in the hall 'he hit me he hit me' when I walked on the hall she was walking back to her unit holding her chest saying he hit me. Co resident was in the hallway in a wheelchair at the time. Resident has a reddened area on her mid sternal area with no bruising at this time. Vital signs within the resident's normal limits. Resident was removed from he area where she sat in the chair and calmed herself down. message left with POA, charge nurse notified. --8/5/19 at 00:16: rec'd resident anxious et pacing et loud. Routine meds given. stated pain in back but [MEDICATION NAME] is effective an hour later. Resting in bed by 9pm. No additional effects of incident earlier. --8/6/19 at 17:35: Resident has experienced a multitude of outbursts this shift, yelling at everyone in her line of site, cussing, and screaming at the top of her lungs without reason. Resident is also displaying increased agitation. Placed on concern board for MD. Will continue to monitor. --8/6/19 at 22:06: Resident has displayed increased agitation / anxiety during this HS med pass. She is going into the bathroom, turning on the faucets, then will start screaming profanities very loudly when attempting to redirect her. She shouts, 'I'm leaving. I'm going home, I'm not coming back, F--- you. Attempted to redirect resident with different snacks, juices, but with no success. Took HS medication without incident. --8/7/19 at 02:26: Resident ist still awake and has not been to sleep yet tonight. She has woken several other residents on the hall by screaming. Unable to get her into a recliner or into her bed. --8/7/19 at 15:15: This resident was standing out in the hall and resident #9152 rolled up to her and hit her in the stomach. Resident yelled out and resident #9152 rolled on down the hall in his w/c (wheelchair). --8/21/19 at 06:20: Resident seems agitated with staff and with other residents. Attempted to redirect her. Offered snack/drinks. Walked briskly through the halls and was saying, 'I'm leaving, I'm leaving. It hurts, hurts, hurts, blood, blood.' PRN [MEDICATION NAME] per MD order. --8/23/19 at 23:20: Resident was getting into the towels and wash clothes and had them in the floor in the bathroom. Going into other residents rooms while they are sleeping. [MEDICATION NAME] 1mg po given. --8/28/19 at 02:06: Resident with increased agitation, attempting to get into bed with other residents, yelling at Staff, attempts were made to help Resident get comfortable, PRN [MEDICATION NAME] administered, will continue to monitor. --8/30/19 at 04:34: Resident showing increased agitation during HS (at bedtime) med pass. She was going into other residents rooms, climbing into their beds, screaming out. Unable to redirect to a recliner or with a snack. PRN [MEDICATION NAME] administered per MD order. --08/31/19 at 06:35: Resident was very agitated, pacing the halls, yelling out at other residents. Offered a snack/drink; Unable to redirect at this time. PRN [MEDICATION NAME] given at this time, per MD order for agitation. --09/05/19 at 07:15: Resident already agitated this morning, yelling and pacing. PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered. Will continue to monitor. --09/05/19 at 11:55: Administered second dose of PRN [MEDICATION NAME] and PRN [MEDICATION NAME] due to the resident expressing being in pain as well as starting to pace and become agitated when being redirected. Will continue to monitor. --09/05/19 at 14:32: Reported by ADON (assistant director of nursing) to this nurse that resident was found lying in another resident's bed on C wing. No incident occurred. Resident redirected out of room / bed. Will continue to monitor. --09/06/19 at 14:12: Resident has not experiences any falls this shift. Anxiety and pain continues with PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered per order. Will continue to monitor. --09/09/19 at 14:33: Resident making false remarks saying another resident hit her. The resident she was accusing is sitting quietly in the hallway with her arms crossed. d) Incident/accident report On 08/04/19 the resident was screaming another resident hit her. Resident #51 was huddled against the wall. Residents were separated. On 08/07/19 the resident was again struck by another resident in the abdomen. e) Resident #22 On 09/09/19 at 1:16 PM, the resident expressed she had problems with Resident #51. She called Resident #51 by her first name and said, I have hit her but only once after she hit me first. I had to stand up for myself. She takes all my stuff. Resident #22 said Resident #51 wants to eat all her food. She goes into my room and takes my stuff. The resident said, Usually staff get my stuff from her and bring it back to my room. She said she didn't have to tell staff because they are all aware of Resident #22's behaviors and they don't do anything about her. Review of the Resident's most recent MDS with an ARD of 06/14/19 found the resident has a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact. This resident was also coded as having no behavior problems. Review of the resident's medical record found no evidence of physical altercations between Resident #22 and Resident #51. On 09/10/19 at 1:15 PM, the Social Work Supervisor (SWS) #56 said she was unaware of a physical altercation between the 2 residents. SWS said, Resident #51, just wanders around the facility. The SWS was unaware Resident #51's behaviors were affecting other resident. f) Resident #66 On 09/09/19 at 1:01 PM, Resident #66 voiced a complaint regarding Resident #51. Resident #66 called Resident #51 by her first and last name and said she goes into my room all the time and takes my stuff. She takes the remote control for the television also. sometimes she scares me because of the way she curses and carries on all the time, I never know what she is going to do. Resident #66 said staff know what she is doing but they can't keep up with her. Review of the Resident's most recent MDS with an ARD of 08/13/19 found the resident has a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact. This resident was also coded as having no behavior problems. On 09/10/19 at 1:15 PM, the Social Work Supervisor (SWS) #56 said, Resident #51, just wanders around the facility. The SWS was unaware Resident #51's behaviors were affecting other resident. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of any problems with Resident #51. On 09/10/19 at 11:52 AM, the surveyor spoke with DON regarding Resident #51. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. During an interview with Employee #131, MDS nurse on 09/10/19 at 2:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been care planned. MDS #131 said she did not know about the residents behaviors, yet she was the same nurse that coded the resident as having the having physical and verbal behaviors. Resident #131 confirmed she was responsible for this resident, her care planning and her MDS. Under the guidance to surveyors, F 600 notes the following: In addition, the risk for abuse may increase when a resident exhibits a behavior(s) that may provoke a reaction by staff, residents, or others, such as: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; Taking, touching, or rummaging through other's property; Wandering into other's rooms/space; and Resistive to care and services. g) Resident #21 According to the quarterly Minimum Data Set (MDS) assessment for Resident #21, with an Assessment Reference Date (ARD) of 07/03/19, Resident #51 has a Brief Interview for Mental Status (BIMS) score of 10. During an interview with Resident #21 on 09/09/19 at 12:15 PM, Resident #21 stated that one resident (Resident #51) bothered her. Resident #21 stated that Resident #51 was getting in other resident rooms when the residents didn't want her in the rooms. Resident #21 stated that she was a resident on the same wing / hall as Resident #51. Resident #21 stated that Resident #51 bothers us when we are trying to eat. She goes through our rooms and messes with our things. She also pours water on the floors in the hallway. You have to keep your door shut to keep her out. On 09/10/19 at 11:52 AM, this surveyor spoke with Director of Nursing (DON) regarding Resident #51. This surveyor interviewed the DON regarding Resident #51's behaviors. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. The DON noted that one of the reasons Resident #51 eats lunch in Special Needs is for her weight loss as well as trying to keep her occupied as to not disturb the residents on A wing. During an interview with Employee #131, MDS nurse on 09/10/19 at 02:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been careplanned. During an interview on 09/11/19 at 10:15 AM, with Employee #103, Therapeutic Program Director, has Resident #51 on caseload. Resident #51 comes to the Special Needs department for meal training, Monday thru Friday for lunch. On the weekends, Resident #51 eats her meals back on unit. Employee #103 noted that Resident #51 was referred to Special Needs for weight loss, meal intake, and to provide more supervision for resident's behavior. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided. h) Resident #11 According to the quarterly Minimum Data Set (MDS) assessment for Resident #11, with an Assessment Reference Date (ARD) of 06/11/19, Resident #51 has a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. During an interview with Resident #11 on 09/09/19 at 12:22 PM, Resident #11 stated that she only had one issue. Resident #11 stated that Resident #51 gets into people's food when they are eating. (NAME of Resident #51) puts her fingers in our food. During the weekdays, they (staff) take her to special needs. But on the weekends, there is not enough staff, so she eats her meals in this (A Wing) dining room. They (staff) need to sit with her so she won't get into people's food. Resident #11 stated that Resident #51 touches other resident's food, paces in the dining room, and yells and rants at the other residents mostly on the weekends. Resident #11 states that she has told staff about her concerns and issues with Resident #51. Resident #11 states that Resident #51 eats in the A wing dining room weekdays for breakfast and dinner and all three meals on the weekends. On 09/10/19 at 11:52 AM, this surveyor spoke with Director of Nursing (DON) regarding Resident #51. This surveyor interviewed the DON regarding Resident #51's behaviors. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. The DON noted that one of the reasons Resident #51 eats lunch in Special Needs is for her weight loss as well as trying to keep her occupied as to not disturb the residents on A wing. During an interview with Employee #131, MDS nurse on 09/10/19 at 02:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been careplanned. During an interview on 09/11/19 at 10:15 AM, with Employee #103, Therapeutic Program Director, has Resident #51 on caseload. Resident #51 comes to the Special Needs department for meal training, Monday thru Friday for lunch. On the weekends, Resident #51 eats her meals back on unit. Employee #103 noted that Resident #51 was referred to Special Needs for weight loss, meal intake, and to provide more supervision for resident's behavior. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided. |
2020-09-01 |