| 61 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2019-03-02 |
609 |
J |
1 |
0 |
KDKT11 |
> Based on interviews and review of the facility's policy titled OPS Abuse Prohibition the Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) failed to report an allegation of physical abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not timely reported to the Alabama State Survey Agency. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the LPN, she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F609. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse . the CED (Center Executive Director) or designee will perform the following: 6.1 Enter allegation into the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . 6.5 Notify local law enforcement, Licensing Boards and Registries, and other agencies as required . On 2/26/2019 at 3:49 PM, an interview was conducted with EI #4, the 2:00 PM to 10:00 PM (2nd shift) Licensed Practical Nurse (LPN) assigned to work on the Homestead (Dementia) Unit. EI #4 was asked if there was another altercation involving RI #1 on 2/20/2019. EI #4 said yes. EI #4 said she heard someone yelling and saw of the aides running up the hall. Later, EI #4 was told that RI #1 was beating RI #2 in the head. EI #4 said she called the DNS. According to EI #4, the DNS told her not to document and that she would take care of it the next day. EI #4 stated the next day around 9:30 PM, RI #1 was picked up and taken to a geri-psychiatric setting. During an interview with EI #2, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), on 2/28/2019 beginning at 9:36 AM, she was asked if resident-to-resident altercations were reportable to the Alabama State Survey Agency. EI #2 said yes. EI #2 was asked what the staff should do when they observe a resident-to-resident altercation. EI #2 explained the staff are required to call the Abuse Coordinator, who is the facility's Administrator, document the altercation in the RMS (Risk Management System), complete a change of condition report, notify the physician and resident's family; and start to give instructions to the staff on duty. EI #2 acknowledged that none of this was done. When asked why the staff first notified her of the 2/15/2019 resident-to-resident altercation between RI #1 and RI #2, EI #2 said because she had the staff call her for everything. EI #2 stated after the staff calls her, she informs the Administrator. When asked if the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 should have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegations within two hours. When asked why would the staff state she was notified of the 2/20/2019 altercation shortly after it occurred and was told to not do anything and that she (EI #2) would take care of it in the morning, EI #2 replied I don't know. I would never do that. When asked when she became aware of the resident-to-resident altercation that occurred on 2/20/2019, EI #2 stated it wasn't until the State Surveyor informed her last night (2/27/2019) and two people came into her office on yesterday asking what happened with RI #1. When asked who those two people were, EI #2 said she couldn't remember because people constantly come in and out of her office. In an interview with EI #1, the Center Executive Director, also known as the Administrator on 2/28/2019 at 12:25 PM, he acknowledged the 2/20/2019 incident that occurred between RI #1 and RI #2 was a reportable incident to the Alabama State Survey Agency. According to EI #1, he was not made aware of the incident until 2/27/2019 by a representative from the Alabama State Survey Agency. When asked what he expected the staff to do when they became aware of the incident, EI #1 said the Charge Nurse should have notified the Abuse Coordinator, the physician, and the Supervisor; the notifications of all parties should have been documented in the residents' medical records; an assessment should have completed and documented for both residents; an incident report should have been completed; and the provision of 1:1 supervision for RI #1 should have been reinforced. EI #1 acknowledged none of this was done. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F609, which documented: F-609 J- Reporting of Alleged Violations Licensed Nurse discharged RI #1 to Baptist Senior Care Unit on (MONTH) 21, 2019. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be reported to the Center Executive Director, who is the Abuse Prevention Coordinator. Center Executive Director submitted an online report with the State Agency on (MONTH) 27, 2019 related to the resident to resident altercation occurrence on (MONTH) 20, 2019. The Nurse Practice Educator or designee educated 95 of 95 active employees from (MONTH) 27, through (MONTH) 2, (YEAR) on the Abuse Prohibition policy and procedure to include reporting of incidents. Employees on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires are educated on the Abuse Prohibition policy related to reporting during orientation. The Nurse Practice Educator or designee interviewed staff on (MONTH) 2, 2019, concerning knowledge of unreported instances of abuse, neglect, misappropriation, or mistreatment, to include resident-to-resident altercations. No concerns were identified. Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on the Abuse Prohibition policy and procedure to reporting of incidents on (MONTH) 1, 2019. Quality Assurance Performance Improvement (QAPI) meeting held on (MONTH) 1, 2019 with Interdisciplinary Team members and reviewed with the Medical Director (via phone) on the center's Abuse Prohibition policy. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F609 was lowered to a D level on 3/2/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 156. |
2020-09-01 |