cms_WV: 5147
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5147 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2015-06-23 | 223 | K | 0 | 1 | PDA311 | Based on observation, resident interviews, staff interviews, clinical record review, review of facility records, and facility policy and procedure review, the facility failed to ensure the safety of residents after an allegation of resident to resident sexual abuse. Resident #72 alleged Resident #79 touched her inappropriately. She reported it to a licensed practical nurse (LPN) on 06/13/15; however, the nurse did not report the allegation and an investigation was not immediately initiated. In addition, no efforts were made to protect other facility residents from sexual abuse from Resident #79, who was able to move freely throughout the facility. Investigation during the survey revealed the allegation was brought to the facility's attention in a morning meeting on 06/15/15. Although the facility initiated an investigation at that time, the facility did not put measures in place to protect the residents from sexual abuse by Resident #79. As of 06/16/15, during the survey, measures to protect the residents had not been put into place. Another resident, Resident #2, stated she was made aware of the situation by Resident #79 (the perpetrator). She said she was afraid Resident #79 would do something to her also. On 06/16/15 at 6:58 p.m., the Administrator and Director of nursing (DON) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to protect residents during the investigation of an allegation of abuse. On 06/16/15 at 8:43 p.m., the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated. The P[NAME] included: Immediate Jeopardy has been identified based on failure to report an allegation of sexual abuse in a timely manner; to protect residents from potential harm during the investigative process; and, to implement the facility policy and procedure regarding abuse. On 06/15/15 at approximately 9:15 AM, the Director of Nursing informed Administrator of a progress note written on 6/13/15 by LPN stating that a female resident had reported to her that a male resident had touched her breast. Social Worker immediately interviewed resident and resident reported that it had happened on 06/13/15 at approximately 6:30 PM. After Social Worker confirmed the resident's statement, Social Worker reported this allegation to state agencies at approximately 11 AM. Shortly after reporting the initial reportable, female resident told Social Worker that same male resident had come into her room on the night of 06/14/15 at approximately 11 PM and touched her vagina. Social Worker then called the police and spoke to dispatch about the allegation and (name of) County dispatch said they would send an officer right away. After waiting approximately 45 minutes for the officer to come, Administrator phoned (county name) dispatch to see if they had dispatched an officer and they confirmed they had. Shortly after Administrator phoned the dispatch, Officer #1 arrived at the facility to interview the residents involved in the allegation. Officer #1 took female resident ' s statement and came back 2-3 hours later to complete male resident ' s statement with another officer, Officer #2. While the officer was out of the facility, female resident was under constant supervision and male resident stayed in his room. Female resident was then sent to (name of hospital) for a sexual assault medical examination. Licensed nurse who failed to report allegation of abuse immediately to supervisor was suspended pending investigation on 06/16/15 by Director of Nursing. Social Worker who failed to properly report allegation to the appropriate state agencies was reeducated on 06/16/15 by Administrator. Reeducation of all staff on abuse reporting has started on 06/16/15 by Nurse Practice Educator and/or designee and will be completed by 06/17/15 or prior to working next shift. Staff interviews regarding alleged abuse investigation have started on 06/16/15 by Nurse Practice Educator/management designee and will be completed by 06/17/15 or prior to working next shift. All interviewable residents were interviewed on 06/16/15 by Nurse Practice Educator and/or designee with no additional findings. Male resident involved in allegation was moved to a private room and different hall on 06/16/15 at 5:30 p.m Male resident involved in allegation will be placed on one-on-one supervision beginning on 06/16/15 at 8:48 p.m. and will be on one-on-one supervision until the sexual assault medical investigation results are received by the facility. On 06/17/15 at 9:45 p.m., Resident #79 was observed in a private room on a different unit. A staff member was sitting outside the room. After the plan of correction for the immediate jeopardy was implemented, a deficient practice at a scope and severity of D remained for failure of staff to immediately report the allegation, and failure of the facility to implement its policies. This deficit affected two (2) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #72, #2, and #79. Facility census: 55 Findings include: a) Resident #72 The resident's clinical record review, on 06/16/15 at 4:00 p.m., revealed an 08/27/14 physician's determination the resident had capacity to make health care decisions. According to the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/29/15, Resident #72 had a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15, the highest possible score on the BIMS, indicated the resident was cognitively intact. Review of a nurse's note, dated 06/13/15 8:42 p.m., revealed Resident #72, . told me also this morning that another resident touched her boob. She said it was not the first. I educated her to please stay away from that resident. The nurse's note was written by Licensed Practical Nurse (LPN) #64. In an interview on 06/16/15 at 3:38 p.m., Social Worker (SW) #8 stated she became aware of the abuse allegation on 06/15/15 at the morning meeting. SW #8 stated Resident #72 reported to her during an interview, that Resident #79 touched her left breast on 06/13/15. The SW said Resident #72 stated she reported the incident to LPN #64 that same day. SW #8 stated she had not completed any further investigation with any residents or staff regarding the allegation. b) Resident #2 The resident's clinical record review was conducted on 06/16/15 at 4:00 p.m. An 04/25/15 quarterly MDS indicated the resident had a BIMS score of 15, identifying the resident was assessed as cognitively intact. During an interview, on 06/16/15 at 3:34 p.m., Resident #2 stated Resident #79 told her he touched Resident #72 inappropriately and raped her. Resident #2 stated, I am afraid to sleep, because he might do something to me. c) Resident #79 On 06/16/15 at 3:42 p.m., Resident #79 was observed lying on his bed in his room. Review of the resident's medical record on 06/15/15 at 3:30 p.m., found his admission MDS, with an ARD of 05/07/15, identified his BIMS score was 15, indicating he was cognitively intact. It also identified he was independently mobile. At 4:08 p.m., on 06/16/15, the Director of Nursing (DON) stated the facility instructed Resident #79 to stay away from Resident #72. The DON confirmed Resident #79 resided on the same hall as Residents #72 and #2. Upon inquiry, the DON stated she became aware of the abuse allegation on 06/15/15 in the morning. She said she informed the day nurse of the allegation, but provided no instruction to staff for protection of residents during the investigation. During an interview on 06/16/15 at 4:20 p.m., the Administrator and DON stated they became aware of the abuse allegation on 06/15/15 in the morning. They confirmed LPN #64 should have reported the allegation immediately on 06/13/15. The Administrator stated Resident #72 was sent to the hospital for evaluation and police were notified of the allegation. The Administrator and DON confirmed Resident #2 was ambulatory both in and out of the facility. They confirmed they put no protective measures in place for residents during the facility's investigation. d) Review of the facility's policy and procedure entitled Abuse Prohibition, dated as revised on 07/16/13, was conducted on 06/16/15 at 6:25 p.m. The policy stated . If the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. Options for room changes will be provided based on the situation. The policy also stated the center would . conduct an immediate and thorough investigation. According to the policy, The Center will protect patients from further harm during the investigation. Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. e) In a follow-up interview on 06/17/15 at 10:40 a.m., SW #8 indicated she would now interview the victim immediately and then wait for further instruction from the administrator. SW #8 stated she reported Resident #72's allegation against Resident #79 to OHFLAC on 06/16/15 in the evening. Review of facility records revealed a fax receipt to OHFLAC on 06/16/15 at 5:06 p.m. f) During an interview, on 06/17/15 at 11:15 a.m., Assistant Director of Nursing (ADON) #16 stated she was on call the weekend of Resident #72's allegation on 06/13/15. ADON #16 stated LPN #64 did not report the allegation to her as required by facility policy. g) On 6/17/15 at 11:29 a.m., Nurse Practice Educator (NPE) #65 stated she provided new education for staff regarding abuse and neglect starting 06/16/15. NPE #65 stated she conducted interviews of staff and residents since 06/16/15, but did not identify any new allegations of resident abuse. h) Review of in-service records on 06/17/15 at 1:40 p.m., revealed 43 staff members had completed in-service training regarding abuse and neglect since 06/15/15. i) On 06/17/15 at 1:40 p.m., 42 staff statements conducted by the facility were reviewed. No additional concerns of resident abuse or neglect were indicated. j) During an interview on 06/17/15 at 12:36 p.m., LPN #64 indicated she had been trained to immediately report any allegation of resident abuse to the supervisor or other management staff. At that time, the LPN confirmed she had written the 06/13/15 at 8:43 p.m. nurse's note in Resident #72's clinical record. LPN #64 stated, When you think of abuse, I think staff to resident and didn't think about residents with capacity not so much as abuse. I should have reported it immediately. | 2019-03-01 |