cms_WV: 4043
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4043 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 319 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident interview, and staff interview, the facility failed to ensure that a resident who displayed and/or was diagnosed with [REDACTED]. Resident #29 was admitted to the facility with a history of inpatient and outpatient treatment for [REDACTED]. The primary care physician #181 was notified of her aggressive behaviors and sexual comments on 10/18/16. Despite further notifications, no medication adjustments were made until 01/19/17. In addition, no psychological assessments or behavior management plan was provided when the resident's behaviors towards others increased in (MONTH) (YEAR). This was found for one (1) of one (1) residents reviewed for behaviors. The resident's behaviors had the potential to affect more than a limited number of the resident's fell ow residents. Resident identifier: Resident #29. Facility census: 61. Findings include: a) Resident #29 During an observation of the noon meal service on 02/13/17, Resident #29 was observed attempting to pinch a male nursing assistant's bottom as he escorted her to her table. Random observations on 02/22/17 and 02/23/17, found Resident #29 roaming freely throughout the unit and at times making inappropriate sexual comments to State Surveyors. Resident #29 repeatedly spoke about her desire for sexual relations as well as making comments about her lady parts. Licensed Practical Nurse (LPN) #119 was interviewed on 02/22/17 at 3:46 p.m. and reported Resident #29 was aggressive at times and had to be removed from activities because she makes loud inappropriate sexual comments about men and male visitors. Review of the medical record on 02/28/17 at 9:30 a.m., revealed Resident #29 was admitted to the facility in 2011. Her current [DIAGNOSES REDACTED]. She was independent with most of her activities of daily living and allowed to ambulate independently throughout the first floor of the facility. The nurses' behavior documentation from 09/01/16 through 09/20/16 identified the following behaviors exhibited by Resident #29: -- 09/06/16 - The Director of Nursing (DON) wrote (typed as written): RESIDENT WAS WALKING APAST ANOTHER RESIDENT IN HALLWAY BY NURSES STATION HEARD A LOUD dont do that and she hit resident on arm. she stated resident touched her when she walked by this wasn't witnessed.resident redirected -- 09/11/16 - LPN #171 wrote (typed as written): resident agruing (sic) with another resident redirected becomes upset -- 09/13/16 - LPN #180 wrote: .Resident sexually inappropriate this morning. She stated to this LPN Is this going to give me 8 inches. Am I the only woman in this place looking for sex. I mean, I like dick. Resident redirected . -- 09/14/16 - LPN #171 wrote (typed as written): resident slapping at other resident redirected -- 09/29/17 - LPN #180 wrote: .Resident redirected on several occasions today due to making sexually inappropriate comments . The nurses' behavior documentation from 10/01/16 through 10/31/16 identified the following behaviors exhibited by Resident #29: -- 10/17/16 - LPN #171 wrote (typed as written): sexually inappropriate with males. -- 10/18/16 - The minimum data set (MDS) / Registered Nurse (RN) #111 wrote: Interdisciplinary care plan meeting held .Staff continues to monitor and redirect as needed due to inappropriate comments to male visitors/staff. -- 10/18/16 - LPN #180 wrote: .Resident observed to slap resident (number) across left side of his face as he set down at table for lunch. Resident (#29) began yelling at (Resident number). (Name) Resident #29 was redirected, calmed down and then relocated to her normal table for lunch . Dr. #181 (name) aware. U/A c&s (urinalysis with culture and sensitivity) ordered. -- 10/21/16 - RN #153 wrote in her monthly assessment (typed as written): [AGE] year old female with HX (history): DEPRESSION, .AGGRESSIVE BEHAVIORS SEXUAL TALKING AND TOUCHING AT TIME NOTED .ANXIETY, DEMENTIA, .ambulates independently . The nurses' behavior monitoring documentation from 11/01/16 through 11/30/16 notes the following: -- 11/02/16 - LPN #189 wrote, .Resident states when drinking her prosource I gotta get all the sperm I can from this shot. -- 11/08/16 - RN #111 wrote, Dr. (name of #181) in to see resident concerning the note that he received about resident this past quarter and her physical altercations with other residents - states not going to make medication adjustment at this time but if episodes seem to occur more frequently then he will adjust medications - staff to continue to monitor and intervene if necessary. -- 11/10/16 - LPN #180 wrote, .Resident redirected this morning due to inappropriate sexual conversation attempt with the LPN . -- 11/14/16 - LPN #171 wrote, sexually inappropriate with other residents and staff redirected. -- 11/15/16 - LPN #180 wrote, .Resident relocated away from resident (number) earlier this shift due to verbal aggressiveness toward resident . The nurses' behavior monitoring documentation from 12/01/16 through 12/31/16 identified the following behaviors: --12/18/16 LPN #119 wrote, Resident making inappropriate sexual comments around visitors of other residents. Resident redirected with short success. --12/20/16 LPN #171 wrote (typed as written), redirected from male resident many times she was yelling at him attempting move him away from her table (typed as written). --12/22/16 LPN #119 wrote, Dr. #181(name) made rounds. Orders received for CMP (complete metabolic profile) and fasting lipids. No other orders at this time. The nurses' behavior monitoring documentation from 01/01/17 through 01/31/17 noted the following behaviors: -- 01/05/17 - LPN #171 wrote, resident yelling at other residents redirected becomes angry. -- 01/09/17 - LPN #119 wrote, Inappropriate comments relating to sex made to staff. -- 01/10/17 - LPN #119 wrote, Resident attempted to strike another resident that was invading her space. Resident upset when this nurse told her not to touch the other resident. This nurse asked the resident to speak with her and the resident was angry and said NO and walked away -- 01/13/17 - LPN #119 wrote, SBAR (situation, background, assessment, recommendation) faxed to Dr. (name) in regards to residents increased agitation. Resident has been attempting to hit/push other residents when she feels they are invading her personal space. Resident states that she should be able to defend herself when someone comes to close to her. Possible psych eval (psychiatric evaluation) or medication change requested. -- 01/14/17 - LPN #119 wrote, Resident had completed her lunch and joined in a birthday party for another resident. This nurse had to ask the resident to come to her room d/t (due to) inappropriate behavior w/ (with) visitors. Resident was overheard by staff making suggestive sexual comments, using explicit language, to male visitors while in front of 4 children, ages 5-15 . -- 01/15/17 - LPN #119 wrote, Resident making inappropriate comments to staff about sex. Tells group of ladies at her lunch table that she hopes the ranch dressing tastes like sperm. -- 01/17/17 - The minimum data set (MDS) / Registered Nurse (RN) #111 wrote, Discussed in interdisciplinary careplan meeting .Dr. #181 (name) was notified last week regarding inappropriate comments/more physical aggression and not received a response yet The behavior monitoring nurse's note written by the Minimum Data Set (MDS) nurse on 02/01/17 stated, .Her [MEDICATION NAME] was increased 1/18 for depression and to help deter her sexual inappropriateness - also at times gets physical/verbal with other residents if they are in her space. She is forgetful. Staff continues to monitor and address her needs and try to redirect when she makes inappropriate comments about sex or gets in male visitors space Social Worker #110 stated in her summary on 11/02/16, .up and about daily. She does have some inappropriate talk about sex and men. She is often redirected On 01/18/17, Activities Director #109 wrote in her quarterly progress note, .at times will have some behavior problems, where she is mean with other staff and residents The physician progress notes [REDACTED].Nursing reports [MEDICAL CONDITION] and aggressive behavior, when people enter her personal space Under the Objective heading it stated, .Evaluation does reveal provocative and [MEDICAL CONDITION]. The Impression was, .5. Hypersexual and aggressive behavior. The antidepressant [MEDICATION NAME] was increased to 40 milligrams (mg) daily. The physician's progress note dated 02/16/17 stated under the Subjective heading, .Last month [MEDICATION NAME] was increased to 40 mg daily in hopes of minimizing [MEDICAL CONDITION]. Not very effective. The Impression section included, 4. [MEDICAL CONDITION]. The plan was, Continue medications and supportive care. The most recent psychiatric consult in the record was dated 03/26/14. The physician noted the resident was referred because of her recent inclination to make sexually inappropriate comments to males in her environment. The psychiatrist suggested a trial of [MEDICATION NAME] (antidepressant) for attenuation of her libido and added mood stabilizers may be considered. On 02/28/17 at 3:30 p.m. Resident #29's medical record was reviewed with the Director of Nursing (DON). She acknowledged Resident #29 had a long history of mental illness which included depression, [MEDICAL CONDITION], anxiety, and dementia and she was treated multiple times at a psychiatric facility prior to her admission to long term care. Resident #29's aggressive behaviors towards others and sexual comments increased in (MONTH) (YEAR). The DON acknowledged the primary care physician increased the resident's [MEDICATION NAME] in an attempt to minimize her behaviors and his follow up note on 02/16/17 noted the medication increase was not very effective. The DON confirmed Resident #29 had not had a psychiatric evaluation since 03/26/14 and no other treatment had been implemented to address Resident #29's behaviors. Resident #56 was interviewed on 02/28/17 at 11:20 a.m. She stated Resident #29, has a dirty mouth, and makes inappropriate comments that make me feel uncomfortable. Resident #56 stated she often tells Resident #29 to shut up and go away even though she is not supposed to. | 2020-02-01 |