cms_WV: 5007
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5007 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 226 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, facility record review, and policy review, the facility failed to implement its written policies prohibiting mistreatment, neglect, and abuse of residents. The facility failed to conduct a thorough investigation, failed to report occurrences, and failed to ensure residents were protected from harm during an investigation. This affected two (2) of three (3) residents reviewed for allegations of abuse. Resident identifiers: #33 and #27. Facility census: 57 Findings include: a) Resident #33 During an interview with Resident #33 and his wife, on 04/18/16 from 4:04 p.m. to 4:45 p.m., an inquiry as to whether the resident had experienced abuse or neglect, revealed an incident involving the administration of [MEDICATION NAME]. Resident #33's wife recounted an incident on 04/05/16, concerning the administration of [MEDICATION NAME], and how it was actually a misunderstanding. His wife said Resident #33 thought he was receiving Tylenol, but was actually receiving [MEDICATION NAME]. She related Licensed Practical Nurse (LPN) #60 came to the room and said, We need to talk. Resident #33 and his wife related the nurse told the resident that she did not appreciate him reporting her to the administrator. His wife indicated the nurse spoke in an angry and confrontational manner and that LPN #60 thought Resident #33 should have known what he was receiving. She said the nurse came in again the next evening and asked, Do you know what this is? The resident had replied, Tylenol? and the nurse responded, No it's (it is) your [MEDICATION NAME]. The resident related his wife had apologized to LPN #60 for the misunderstanding. During the interview, on 04/18/16, Resident #33's wife said she called her husband on 04/06/16, the evening after the confrontation with LPN #60. She related the resident informed her that he was up in his chair and they would not put him to bed. The resident had told her LPN #60's husband, Nurse Aide (NA) #82, who was a nurse aide on the 100 hallway, was helping on the 200 hallway and would walk by and glare, but would not come into the room and did not help put him to bed. Resident #33's wife further added, RN #20 had come to the room the date of the confrontation by LPN #60 and the LPN exited the room with the RN. Both the resident and his wife related no one had responded to their concern about the way they were treated by the nurse and the nurse aide. The wife related she had contacted the corporate office. Resident #33 and his wife related she had spoken with Registered Nurse (RN) #20 and the social worker on a three (3) way call on 04/08/16. The concern/grievance log book and reportable allegation log book, reviewed on 04/18/16 at 5:00 p.m., revealed no evidence of Resident #33's concerns. During an interview on 04/19/16 at 4:30 p.m., RN #20, acknowledged she was aware of Resident #33's allegations. She said it was a concern that was a mixture of things which were misinterpreted, and the complaint had come through the compliance line from the corporate office. RN #20 related she would check the administrator's office, and returned with the complaint reported on the compliance line. The RN related, It was all a big misunderstanding. She said Resident #33 thought he had not been given his medication and had reported it to administration. She related LPN #60 did speak with the resident about the incident on 04/05/16, and the next evening (04/06/16), and NA #82 was assigned to Hallway 100, but assisted the NA on Hallway 200, where Resident #33 resided. RN #20 stated the nurse aide had informed her he may have glanced at the room as he was passing by and related he did not assist to transfer the resident to bed. According to RN #20, the resident was not assisted to bed when requested, and was returned to bed about 8:10 p.m. She related when she had inquired, LPN #60 related she wanted him to stay up for two (2) hours after dinner, to prepare him for discharge. Review of the care plan, on 04/19/16, revealed no evidence of a care plan requiring the resident to stay up in his chair. The care plan indicated staff should encourage the resident, but that he should remain up in his chair as tolerated. The RN added that during this time, the social worker had called Resident #33's wife on 04/06/16 to set up a discharge-planning meeting and his wife had expressed to the social worker that she thought it was retaliation because of reporting the concern about the [MEDICATION NAME]. RN #20 related she had received the complaint from the compliance line on 04/07/16 and responded to corporate office on 04/08/16. She related she did not report the allegations because she believed it was all a misunderstanding. The compliance line information received by the facility on 04/07/16, reviewed with RN #20 at 4:40 p.m., revealed the caller stated her husband waited for over two (2) hours to be transferred to his bed after the dinner meal. The caller also stated that (LPN #60's name) jumped on her and the resident for reporting her (the nurse); and that (names of NA #82 and LPN #60) walked by the resident, staring at him to cause an uncomfortable situation. The complaint also indicated the social worker left her a message of a meeting on 04/11/16 to discuss Resident #33's discharge and that he was not ready to be discharged . RN #20's written response to the allegations made on the compliance line, dated 04/08/16, indicated she and the social worker contacted Resident #33's wife regarding her complaint. The report included, The nurse previously confirmed that the conversation had occurred Additionally, the report indicated RN #20 spoke with NA #82 regarding the incident and NA #82 acknowledged being on the hallway assisting another NA. The report indicated the facility would be observant of any behaviors exhibited by (names of NA #82 and LPN #60) which may be perceived as making (Resident #33 and his wife) uncomfortable. The incident details of the report noted Resident #33, Was gotten out of bed a few minutes after 5 pm to eat dinner. He was assisted back to be at 8:10 pm that evening. During the interview with RN #20 on 04/19/16 at 4:30 p.m., she acknowledged the facility failed to complete a thorough investigation, as only the alleged perpetrators were interviewed related to Resident #33's allegation of verbal abuse, mental abuse, and neglect. Additionally, she acknowledged the allegations of abuse and neglect had not been reported to the appropriate State agencies. While reviewing the written response to the compliance line with RN #20, on 04/19/16 at 4:40 p.m., she related she had not interviewed any staff on duty the night of the allegation of neglect (leaving the resident up for over two (2) hours after dinner), or regarding NA #82's demeanor. The RN related she did not realize the allegations required reporting, because the complaint was received on the compliance line. An interview with the social worker, on 04/20/16 at 9:00 a.m., revealed she had participated in the phone conversation related to the issue about medications, but could not remember exactly what was discussed. She related she did not follow-up on the allegations, and did not handle that situation. During an interview with Unit Manager (UM) #58 and the administrator, on 04/20/16 at 9:50 a.m., the administrator related, Yes, I see where you are going with this. We did not report it and should have. b) Resident #27 Reportable allegations, reviewed on 04/20/16, revealed a substantiated allegation of verbal abuse with an incident date of 03/19/16. The immediate reporting form indicated the facility reported the allegation late to the appropriate State agencies. According to the report, Nurse Aide #103 made derogatory remarks to Resident #27 and told her to Shut her damn mouth. The report noted the resident was resisting with transfers and (NA #103's name) said, You need to stop it or I will have to put your ass on the floor The report also noted Resident #27 was mentally incapacitated, elderly, frail, and in a wheelchair (w/c). Witness statements indicated the allegation was first reported to Licensed Practical Nurse #47, who was working as an NA on that date (03/19/16). The nurse's statement included that she did not feel it was her place to act, and that it should have been reported to the charge nurse on duty. Registered Nurse #49's statement noted she was informed of the allegation on 03/21/16, and after speaking with NA #71, informed DON (director of nursing) of what I had been told. The witness statement by the social worker indicated she became aware of the incident on 03/23/16, at which time she reported it. During an interview with the administrator on 04/20/16 at 11:42 a.m., she related, We marked it as reporting late didn't (did not) we? The administrator agreed the incident should have been reported when identified. NA #103's time card, reviewed with Bookkeeper #28, on 04/20/16 at 11:55 a.m. revealed the NA worked on: -- 03/19/16 from 5:58 a.m. - 2:06 p.m.; -- 03/20/16 from 5:59 a.m. - 10:30 p.m.; and -- 03/22/16 from 5:59 a.m. - 2:00 p.m. (a double shift). During the interview with the administrator on 04/20/16 at 12:30 p.m., she acknowledged the facility failed to ensure Resident #27's safety by allowing NA #103 to work on 03/19/16, 03/20/16, and 03/22/16. The administrator acknowledged the allegation of verbal abuse should have been reported to the appropriate State agencies immediately. A follow-up interview with the administrator, on 04/20/16 at 1:30 p.m., confirmed NA #103 had worked during the interim when the allegation was first reported to LPN #47 on 03/19/16 and the date reported on 03/23/16. She confirmed the facility had not ensured the safety of the resident(s). c) The abuse prohibition policy, reviewed on 04/20/16 at 8:45 a.m., indicated the center staff would do all that was within their control to prevent occurrences of abuse, neglect . Section 4.1 indicated the facility would provide patients, families, and staff with information on how and to whom they may report concerns, incidents, and grievances without fear of retribution and provide feedback regarding the concerns that have been expressed. Section 5 indicated the notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the Administrator or designee and other officials in accordance with state law The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation Section 6 noted the facility would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury and Ensure that documentation of witnessed interviews is included. | 2019-04-01 |