| 91 |
BONNIE BLUEJACKET MEMORIAL NURSING HOME |
535019 |
388 SOUTH US HWY 20 |
BASIN |
WY |
82410 |
2017-04-06 |
225 |
E |
0 |
1 |
508H11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interview, medical record review, and policy and procedure review, the facility failed to ensure abuse allegations were investigated for 2 of 3 abuse allegations which involved 2 sample residents (#17, #21). Further the facility failed to ensure pre-hire screening was performed for 3 of 9 employees (CNA #2, CNA #4, RN #1) prior to resident contact. The findings were: 1. Review of the 3/27/17 significant change MDS assessment showed resident #17 had a BIMS (brief interview for mental status) score of 15 (cognitively intact), was able to understand and be understood and required extensive assistance of 2 or more people for bed mobility, transfers, dressing, and toilet use. The following concerns were identified: a. Interview with the resident's family member on 4/5/17 at 9:40 AM revealed the resident was afraid of CNA #2. The family member stated the CNA is rude and rough with the resident and forces the resident to use his/her injured arm to transfer which causes the resident significant pain. The family member stated the concern was taken to the DON; however, nothing gets done. The family member felt that if the CNA got in trouble for not caring for the resident then the resident would be retaliated against by the CNA not answering his/her call light or not providing assistance. Further, the family member was concerned about reporting the concern again out of fear the facility would discharge the resident. b. Interview with the resident on 4/5/17 at 1:50 PM revealed CNA #2 was physically rough with him/her during cares and it caused the resident pain. The resident felt the CNA was impatient and told him/her to get up without providing assistance and the CNA got louder when she was upset with the resident. Further, the resident stated s/he felt uncomfortable, like a burden, embarrassed, and intimidated by the CN[NAME] The resident revealed s/he had previously reported the CNA behaviors to the nurse and was told the nurse would talk to the CNA about it. The behavior did not improve and the resident revealed s/he was afraid to bring it up again. 2. Review of the admission assessment dated [DATE] showed resident #21 had [DIAGNOSES REDACTED]. Further the resident was able to understand and be understood, and required total assistance of one person for bed mobility, transfer, and toilet use. The following concerns were identified: a. Interview with the resident on 4/4/17 at 9 AM revealed s/he reported concerns about staff and was told s/he can go someplace else. Further, the resident revealed that CNA #2 was rude and rough when she provided care and the resident had expressed this to the nurses before. b. Review of a nurse's note dated 1/11/17 and timed 12:42 AM showed the resident reported s/he did not like the CNA that was in here. The nurse talked to the resident 1 to 1 at that time. c. Review of a nurse's note dated 1/13/17 and timed 11:30 AM showed the resident had complained about care that was provided. The nurse told the resident s/he needed to express his/her concerns to the DON and if (s/he) is not happy in this facility (s/he) could always consider another facility. d. Review of a nursing note dated 1/15/17 and timed 1:50 PM showed the resident reported that aides were not taking him/her to the bathroom during the shift and the previous night. Further, the note showed the CNAs stated the resident was visiting with family and the resident was taken to the bathroom after the visit. 3. Interview with the DON on 4/5/17 and timed 2:07 PM revealed she was not aware of any allegations related to resident treatment by CNA #2. Further she revealed an investigation had not been completed related to the allegations. 4. Review of the policy titled Patient Abuse/Unknown Cause of Injury Investigating/Reporting last revised on 5/9/16 showed .Abuse includes such actions as using derogatory language to a patient, rough handling, ignoring resident while giving care, directing patient who need toileting assistance to urinate or defecate in their bed, ignoring any request or need by a resident .2) Reporting: Any patient, family or staff who witness or suspect or have any concern about any resident who may be at risk of abuse will report such incident or concern to immediate floor supervisor on duty immediately. In the case of concern being related to immediate floor supervisor, another staff member may be notified. Immediate supervisor or staff member receiving report must determine most appropriate course of action for patient to ensure patient is removed from abusive situation immediately. Actions may include constant observation of patient by supervisor, staff perpetrator immediate suspension from cares, or other . 5. Review of the employee file for CNA #2 showed a 6/3/03 date of hire and start date. Further review showed evidence CNA registry placement was requested; however, there were no results. In addition there was no evidence of a background check being completed. 6. Review of the employee file for CNA #4 showed a 5/26/16 date of hire and start date. Further review showed there was no evidence of a background check and reference check being completed. 7. Review of the employee file for RN #1 showed a 3/7/11 date of hire and start date. Further review showed there was no evidence of a background check and reference check being completed. 8. Interview with human resources on 4/5/17 at 2:30 PM revealed that she had only been there since (MONTH) (YEAR). She also verified that the information on the three employees was not in the personnel files. 9. Review of the annual in-service for employees provided from HR showed a date of 1/26-1/28/16 for the facility's last annual employee abuse in-service. 10. Review of the policy and procedure titled Employment Verification last revised 5/20/16 showed the process for screening .3) Copies of all background information will be kept in personnel files. 6) No person will be hired for a position prior to licensure verification, background check, and all previous employment history references. 7) Background checks will include all Federal and State required checks, and past job reference. 8) No person with a criminal background related to abuse or theft will be employed in this facility. |
2020-09-01 |