cms_WV: 4013
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4013 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 309 | H | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observations, review of incident reports, resident interview, and staff interview, the facility failed ensure female residents were provided care and services to enable them to physical and mental well-being. The facility failed to ensure it had an effective system to ensure incidents of nonconsensual sexual contact were identified and effectively managed to ensure dependent, cognitively impaired women did not experience loss of dignity, or become anxious or fear additional unwanted contacts. As a result of this systemic failure, Residents #26, #39, #51, #49, #24, #37, and #1 were determined to have experienced actual harm. The facility also failed to ensure a resident (#10) received his scheduled daily morning insulin as prescribed by the attending physician. Eight (8) of twenty-six (26) residents were affected. Resident identifiers: #10, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. The MDS identified her as needing extensive assistance of two (2) persons for bed mobility and for transfer, total dependence for dressing, toilet use, personal hygiene, bathing, and limited assistance of one (1) person with eating. She sometimes understood others and could sometimes understand others. Confidential interviewees (CI) CI #3 and CI #4, in separate interviews, both said they had witnessed male Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. This resident lacked capacity and was not interviewable. A reasonable person would be distressed by this type of assault. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents, nor of notification of the resident's responsible party or physician. Review of the facility's [MEDICATION NAME] for (YEAR) and (YEAR) found no evidence this event was reported to state agencies During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said the incident on 12/08/16 was unwanted and should have been deemed sexual abuse. In an interview on 02/28/17 at 2:30 p.m., the licensed social worker (LSW) said anything that was deemed abuse, neglect, or misappropriation of property was sometimes reported to her. Sometimes she found it on her own. She said neglect also included not being taken care of by staff, and sexual things. She said she, the DON, the administrator, the nurse manager, and the secretary met daily Monday through Friday. At that meeting, they discussed incidents, but they did not always get the incidents the day they occurred for whatever reason. b) Resident #49 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. She presented with inattention and disorganized thinking that came and went, and changed in severity. Her speech was unclear. She sometimes understood others, and responded to simple direct communication only. Pertinent [DIAGNOSES REDACTED]. Confidential interviews with confidential interviewees (CI) #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews found all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses report inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents are known to touch female residents inappropriately over their clothing. She said the incidents of 02/20/17 are the first time she has ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked the resident if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs and told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. This resident lacked capacity and was not interviewable. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. c) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/26/17, found her assesse to have a BIMS score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated the resident had severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission, which she estimated to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once over a month ago she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said Resident #24's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. This resident lacked capacity and was not a reliable interviewee for events. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. d) Resident #37 On 02/22/17, review of the annual minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident had a BIMS score of two (2), with inattention and disorganized thinking present that fluctuated over time. A BIMS score of two (2) indicated severely impaired cognitive functioning. The MDS assessment identified she sometimes understood others and was sometimes understood. Pertinent diagnosed included unspecified intellectual disabilities, and unspecified [MEDICAL CONDITION]. CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she told Resident #62 that he did not need to go into those ladies' rooms, to which he replied, She wanted it. CI #4 said she always reported the inappropriate behaviors to the nurse in charge. CI#5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said she told him no, and he jerked back his hard. This resident lacked capacity and was not interviewable for events. The resident's inability to resist the repeated nonconsensual sexual contact resulted in a determination of actual harm. Although this resident's feelings could not be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. e) Resident #1 On 02/22/17, review of the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/01/16, found her assessed to have a BIMS score of twelve (12). The MDS with an ARD of 12/01/16 assessed her BIMS score of nine (9). Both scores indicated moderately impaired cognitive functioning. CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on her legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. He replied that he did not do anything. She said she reported this to the nurse in charge at the time. On 02/22/17 at 10:00 a.m., Resident #1 was playing bingo unassisted in activities, and was able to carry on conversation. When asked if any of the men at the facility had touched her inappropriately in private parts of her body, she replied in the negative. She said she would not put up with that. f) On 02/28/17 at 1:00 p.m., the information obtained during confidential interviews with numerous staff members was discussed with the director of nursing (DON). She was informed that one (1) or more of the interviewees said that they had witnessed inappropriate touching of female residents by male residents as follows: - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #51. - One of more staff members said they witnessed Resident #62 and Resident #11 inappropriately touched Resident #49. - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #24. - One or more staff members said they witnessed Resident #10 inappropriately touch Resident #37. - One or more staff members said they witnessed Resident #52 inappropriately touch Resident #1. The DON said she was not made aware by the staff that those female residents were inappropriately touched by those male residents, except for one day recently. She said that on 02/20/17 staff reported that Resident #49 was touched inappropriately by two (2) male residents the same morning. She said staff completed incident reports and reported to State agencies for those two (2) events. The DON said their facility policy explained that unwanted sexual touch was sexual abuse, and that should be reported to state agencies. She said the reporting to state agencies was not done because there was no incident report completed on inappropriate sexual touching. She said an investigation was not done because there was no incident report completed for those behaviors. She said the first step was getting the incident report completed, and any staff member could begin an incident report. She said she reviewed the incident reports daily. If there were any incident reports which require reporting to State agencies, then those incidents were assigned to the licensed social worker for follow-up. g) On 02/28/17 at 2:30 p.m., the licensed social worker was informed that one or more staff members in confidential interviews said they witnessed inappropriate touching of female residents by male residents. Those female residents inappropriately touched were Residents #51, #49, #24, #37, and #1. The LSW said she was aware Residents #62, #11, and #10 had sexual behaviors. She said staff should have completed incident reports each time not only for the male perpetrator, but also for the female victim. She said apparently nurses do not do so - that there were some things they need to work on and change to ensure the appropriate parties were notified, incident reports were completed, and the safety of female residents were ensured. The LSW said she had never heard of any inappropriate touching by Resident #52. She said Resident #52 and Resident #1 like each other, but they did not even hold hands and she had never seen any inappropriate behaviors between them. During an interview with the administrator on 02/28/17 at 4:38 p.m., she acknowledged that facility staff did not identify all issues of inappropriate touching and/or sexual abuse they were aware, or should have been aware of, as abuse situations. She said the lack of incident reports of abuse situations led to the absence of investigation into those issues, and failure to report all incidents of abuse to appropriate State agencies. She agreed that these practices led to the failure to protect some of its female residents from further abuse. h) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] had [DIAGNOSES REDACTED]. Resident #26 began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was not completed. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had the behaviors of inattention and disorganized thinking. In addition, the assessment identified the resident had no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. The Activities of Daily Living (ADL) assessment indicated she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfer, walking in room and had total dependence on staff for dressing, toilet use and personal hygiene. This resident is not interviewable. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated, Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. An approach for the goal, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11, and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occur. When asked how an incident of this type was reported, CI #1 stated they put it in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 was moved to Second Floor (12/02/16) to get her away from the men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26's) pants. Resident #26 was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident-to-resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry noted Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 was again found reaching for the crotch of Resident #26 and the residents were separated. All of the incidents of sexual abuse toward Resident #26 would be upsetting by any reasonable person. The resident's inability to resist the repeated nonconsensual sexual contacts resulted in a determination of actual harm. Although this resident's feelings could not always be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. No evidence was found in the medical record to indicate Resident #26 was assessed after the incidents of sexual abuse. In an interview on 02/22/17 at 2:06 p.m., the Director of Nursing (DON) stated that staff did not complete incident reports regarding the sexual abuse of Resident #26 except for the incident on 08/16/16. In addition, she stated because no incident reports were completed, the sexual abuse was not investigated as stated in facility policy and procedure for abuse reporting. The DON was in agreement Resident #26 should have been assessed following these incidents and evidence recorded in the medical record. i) Resident #39 A review of the medical record from 02/13/17 through 03/01/17 revealed Resident #39 was originally admitted on [DATE], had [DIAGNOSES REDACTED]. Review of the resident's annual MDS with an ARD of 06/16/16 found she had no issues with hearing, speaking, and/or vision. The assessment identified she was usually understood and usually understood others. This resident had a court appointed conservator/guardian as she was not competent to act on her own behalf. The Brief Interview for Mental Status (BIMS) score on annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. The following incidents of sexual abuse by alleged perpetrator Resident #10 were noted in the medical record of Resident #10. No evidence was found of the incidents of sexual abuse and/or an assessment of the condition of Resident #26 in her medical record. - 09/28/16 at 14:06 (12:06 p.m.) - Behavior Monitoring nurse's note stated, Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. The MDS Coordinator stated on 02/03/17 at 9:06 a.m., in a behavior monitoring nurse's note for Resident #10 that the SW, DON, and NHA were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) - a CNA/Nurse's Note stated Resident (#10) in female resident room, she (Resident #39) was lying on her bed, male resident sitting on side of her bed, with her hand in his attempting to have her touch him, she attempting to pull her hand away when entering room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. All of the incidents of sexual abuse toward Resident #39 would be upsetting by any reasonable person. The resident's inability to resist the repeated nonconsensual sexual contacts resulted in a determination of actual harm. Although this resident's feelings could not always be ascertained, a reasonable person could experience a loss of dignity, anxiety, stress, anger, and fear. No evidence was found in the medical record to indicate Resident #39 was assessed after the incidents of sexual abuse. In an interview with the Director of Nursing (DON) on 02/22/17 at 2:06 p.m., she stated that no incidents reports were completed regarding the sexual abuse of Resident #39. In addition, she stated because no incident reports were completed, the sexual abuse was not investigated as stated in facility policy and procedure for abuse reporting. The DON was in agreement Resident #39 should have been assessed following these incidents and evidence recorded in the medical record. j) Resident #10 Review of the medical record on 02/21/17 at 1:17 p.m. revealed Resident #10 was initially admitted on [DATE]. His [DIAGNOSES REDACTED]. He was prescribed accu-check (blood glucose monitoring) twice a day, with scheduled [MEDICATION NAME]90 units to be administered in the morning and scheduled [MEDICATION NAME]80 units to be administered in the evening at bedtime and [MEDICATION NAME]10 units scheduled to be administered in the morning before breakfast and [MEDICATION NAME]15 units scheduled to be administered in the afternoon before dinner. A Pharmacy consultation report with Comment issued on 12/07/16: Records show on 11/29/16, 12/03/16, 12/04/16 and 12/05/16 no morning [MEDICATION NAME] given. Recommendation: Please educate nursing on importance of proper dosing and [MEDICATION NAME] doses should not be held. Rationale for Recommendation: Basal insulins, such as [MEDICATION NAME] do not affect blood glucose concentrations immediately after administration. The Diabetic Flow Sheet revealed: ---on 11/29/16 at 0641 (6:41 a.m.) an accu-check was performed with a blood glucose result of 117, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 252. ---on 12/03/16 at 0600 (6:00 a.m.) an accu-check was performed with a blood glucose result of 259, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 245. ---on 12/04/16 at 0641 (6:41 a.m.) an accu-check was performed with a blood glucose result of 128, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered. At 2000 (8:00 p.m.) an accu-check was performed with a blood glucose result of 243. ---on 12/05/16 at 0600 (6:00 a.m.) an accu-check was performed with a blood glucose result of 69, with no morning scheduled [MEDICATION NAME]administered and no Physician notification of the medication not given as ordered or of blood glucose level being below 70 as ordered. At 2145 (9:45 p.m.) an accu-check was performed with a blood glucose result of 383. After reviewing the Pharmacy consultation report dated 12/07/16 and Diabetic Flow Sheet dated 11/28/16 to 12/07/16 on 02/27/17 at 2:10 p.m., the Director of Nursing (DON) agreed the scheduled morning insulin for Resident #10 was not administered as ordered by the physician. She also verified that no physician notification was conducted by the nurse on any of the days the morning insulin was not administered, because absolutely the physician should have been notified on each of those days. The DON stated, I don't know why the nurse held those doses and just glad that he (Resident #10) did not have any complications arising from the insulin being held. Resident #10 required multiple daily insulin doses and had blood glucose results from 11/29/16 to 12/05/16 ranging from 69 to 259 in the morning and blood glucose results in the evening ranging from 243 to 383 reveling he was considered to be an uncontrolled insulin dependent diabetic. Withholding his morning scheduled insulin doses put the resident at risk for potential complications related to his medical [DIAGNOSES REDACTED]. | 2020-03-01 |