| 64 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2019-03-02 |
835 |
K |
1 |
0 |
KDKT11 |
> Based on interview and review of the Center Nurse Executive's job description, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), responsible for the overall operations associated with direct patient care, failed to ensure staff was provided written education on when and how to provide 1:1 supervision of Resident Identifier (RI) #1 and further failed to ensure the 1:1 supervision was implemented from 2/15/2019 until 2/21/2019. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed 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 Licensed Practical Nurse (LPN), she informed the DNS and was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During interview on 2/28/2019, Employee Identifier (EI) #2 stated she now realized that she should have provided written education and had the staff to document that the 1:1 supervision intervention was being implemented for RI #1. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 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 Administration, F835. Findings include: Refer to F600 and F607 The GENESIS HEALTHCARE JOB DESCRIPTION: CENTERS for the position titled Center Nurse Executive with a revision date of 6/16/2017, documented . POSITION SUMMARY: The Center Nurse Executive leads the Center clinical team to fulfill the organization's mission, vision and value. This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct patient care activities . RESPONSIBILITIES/ACCOUNTABILITIES: . Clinical Leadership: . 2.8 Monitors nursing care to ensure positive clinical outcome . During an interview with EI #2, the Center Nurse Executive (CNE), also known as the DNS, on 2/28/2019 beginning at 9:36 AM, she was asked if she was familiar with RI #1. EI #2 said yes. When asked if RI #1 had behaviors, EI #2 said yes, the resident would become aggressive with staff during care and there were resident-to-resident altercations, where RI #1 would strike other residents. When asked what happened during the resident-to-resident altercation that occurred on 2/15/2019, EI #2 said the altercation involved RI #1 and RI #2. The nurse said both residents were ambulating in the hallway and RI #1 mumbled something and then hit RI #2 under the chin without provocation. When asked what interventions were implemented after this altercation, EI #2 said RI #1 was placed on 1:1 and there were no new interventions for RI #2 after the resident was assessed for injury. EI #2 was asked how long RI #1 was to be on 1:1. EI #2 replied, (RI #1) was supposed to be on 1:1 from 2/15/19 until (he/she) was D/C (discharged ) or other placement found or Geri-Psych arrangements could be made. When asked how staff was made aware that RI #1 was to be placed on 1:1, EI #2 said the night the nurse (EI #4) called her and she instructed the nurse to put someone with RI #1 1:1. Then the next morning, EI #2 stated she made assignment sheets and put them on the unit. When asked if RI #1 was 1:1 since 2/15/2019 until discharged , how it was possible that the resident was involved in another resident-to-resident altercation on 2/20/2019, EI #2 replied she didn't know. EI #2 was asked who was responsible to monitoring RI #1's 1:1 to ensure it was being done. EI #2 stated it was the responsibility of the Charge Nurses, but ultimately she was responsible. EI #2 stated there was a certain amount of trust she had with the Charge Nurses that they would do their job. 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. 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 should the 2/20/2019 resident-to-resident altercation involving RI #1 and RI #2 have been reported to the Alabama State Survey Agency, EI #2 said yes. EI #2 stated the general rule was to report the allegation 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. EI #2 was asked if RI #1 was on 1:1 from 2/15/2019 until 2/21/2019, should there have been another physical resident-to-resident altercation. EI #2 replied, It would still be possible but less likely if (RI #1) was on 1:1. EI #2 explained that she only verbally informed the Charge Nurses to place RI #1 on 1:1. EI #2 stated she now realizes that she should have provided written education and had the staff to document that the intervention was being implemented. When asked who was ultimately responsible for ensuring 1:1 interventions were being implemented, EI #2 said she was. ************************* On 3/2/2019 at 7:15 PM, the facility submitted an Allegation of Credible Compliance for F 835, which documented: F-835 J- Administration On (MONTH) 1, 2019, the Director of Clinical Operations educated the Center Executive Director and Center Nurse Executive on ensuring residents are free from Abuse and Neglect, implementing Abuse policies and procedures, reporting alleged violations timely, and investigating alleged incidents. As of (MONTH) 1, 2019, staff were educated that the first contact for suspected abuse, neglect, misappropriation, or mistreatment is to be the Center Executive Director, who is the Abuse Prevention Coordinator. On (MONTH) 1, 2019, Director of Clinical Operations reviewed allegations of Abuse and Neglect in the last 30 days to ensure written Abuse Prohibition policies and procedures were implemented and allegations were reported timely, thoroughly investigated, and residents were protected. No concerns were identified. On (MONTH) 1, 2019, the Director of Clinical Operations hosted a Quality Assurance Performance Improvement meeting with selected Department Managers and reviewed the Abuse Prohibition policy and procedure to ensure residents are free from Abuse and Neglect, Abuse policies and procedures are implemented, alleged violations are reported timely, and thoroughly investigated. ************************** 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 F835 was lowered to a [NAME] 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 |