| 71 |
MERRY WOOD LODGE |
15019 |
P O BOX 130 |
ELMORE |
AL |
36025 |
2018-03-29 |
600 |
D |
1 |
1 |
OSF111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews, and a review of the facility policy titled, Abuse Prohibition, the facility failed to ensure two residents were free from an incident of abuse. This affected RI (Resident Identifier) #s 94 and 2, two of twenty-five sampled residents. Findings Include: A review of the facility policy titled, Abuse Prohibition, with a revision date of 11/28/17, revealed: . POLICY . (name of HealthCare Company) will prohibit abuse, . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Instances of abuse of all patients, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes hitting, slapping, pinching, kicking, . A review of two investigative summaries dated 1/19/18, revealed that on 1/13/18, RI #54 was observed to strike RI #2 and RI #94 with an open hand and sustained a skin tear to his/her hand. RI #54 struck RI #s 2 and 94 while urging the to Come on, let's go home. The Center Conclusion indicated under current definitions, (RI #54, the aggressor) acted in a deliberate manner in striking RI #2 and RI #94. The center's Abuse Coordinator concluded there was no evidence of physical harm as a result of the event. In the absence of physical harm, the Center concluded that physical abuse did not occur. A review of RI #54's Medical Record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 2/15/18, revealed RI #54 had a BIMS (Brief Interview for Mental Status) score of 4 out of a possible 15. This score indicated RI #54 was severely impaired in cognitive skills for daily decision making. A review of the Behavioral Symptoms section of the MDS revealed RI #54 exhibited no physical, verbal, or other behavioral symptoms towards others. A review of RI #2's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Quarterly MDS, with an ARD of 3/20/18, revealed RI #2 had short term and long term memory problems and was severely impaired of cognitive skills for daily decision making. RI #2 was assessed on the MDS as demonstrating no physical, verbal, or other behavioral skills. A review of RI #94's medical record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. RI #94 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, dated [DATE], revealed RI #94 had a BIMS score of 5 out of a possible 15. This score indicated RI #94 was severely impaired in cognitive skills for daily decision making. The resident displayed inattention and disorganized thinking. On 3/29/18 at 5:36 p.m., an unsuccessful attempt was made to interview the resident identified as the aggressor, (RI #54) related to the (MONTH) Facility Reported Incident. RI #54 was uncomfortable and did not remember. On 3/29/18 at 5:40 p.m., an interview was conducted with EI (Employee Identifier) #6, a CNA (Certified Nursing Assistant). EI #6 was asked if she had any knowledge of the alleged abuse. EI #6 responded, she could not even remember this. EI #6 exited the room to retrieve a copy of the interview and returned at 5:47 p.m. EI #6 stated, My mind is blank on this. EI #6 was asked if the interview she had in her hand was done by the Abuse Coordinator after the incident on 1/13/18. EI #6 stated she could not remember. On 3/29/18 at 5:54 p.m., an interview was conducted with EI #5, a LPN (Licensed Practical Nurse). EI #5 was asked if she had knowledge of the alleged abuse that occurred on 1/13/18. She replied, Yes, I was the charge nurse that evening. EI #5 was asked to describe RI #54 and the other residents that were seated at the table in the back of the room. EI #5 reported that RI #54 was sitting at a table on the inside with the wall to his/her right side, another resident to his/her left, and he/she could not get out. EI #5 said RI #54 had started to get restless in the evening and began telling the others it was time to get up and get a ride home. RI #54 was asked to sit down several times so he/she would not fall. EI #5 reported being at the desk. EI #5 was asked how far was she from the residents involved in the incident. EI #5 answered RI #54 was in the adjoining room. EI #5 added it was the full distance or farthermost away from the desk. EI #5 reported RI #54 told RI #94 to get up and come on, let us go. EI #5 said she was heading back there at that time and before she could get there, RI #54 had hit RI #94. When asked how this occurred, EI #5 answered RI #54 got up and reached across the table and slapped RI #94 with an open hand. RI #2 had his/her head down on the table and RI #54 told him/her to move, let him/her get out of there. Almost at that same time, RI #54 reached over and hit RI #2 on the back of the head, kind of like a slap on the back of the head. By this time, EI #5 reported she had made it to where the residents were. EI #5 managed to get to RI #2 before he/she hit RI #54 back. EI #5 reported she and EI #6, a (CNA), had gotten there about the same time. EI #5 reported EI #6 moved RI #54 out of the way and she moved RI #2 at about the same time. EI #5 reported RI #94 was away from the area by this time. EI #5 reported they checked to see if any of the three residents had any injuries and there were none except for a skin tear on RI #54's hand. EI #5 reported they started to notify the DON (Director of Nursing) and others to include the Psychiatrist. EI #5 reported the residents were separated at that time. EI #5 reported these were the actions she had taken in response to the incident. EI #5 was asked how did the alleged perpetrator and victim act towards one another prior to and after the incident and she answered they were just chatting. EI #5 was asked if the alleged perpetrator and/or victim exhibited any behaviors that would provoke one another. EI #5 answered they did not, RI #54 was just having a moment. EI #5 was asked if she reported the alleged abuse to any supervisors/administration and she answered yes. EI #5 was asked who she reported it to. EI #5 responded the DON, (she notified the administrator), the Psychiatrist, and she attempted to notify sponsors. EI #5 was asked what was their response. EI #5 answered the Psychiatrist got placement for evaluation of RI #54 because of aggression towards other residents. EI #5 added the Administrator had called back and interviewed her over the phone. On 3/29/18 at 7:09 p.m., an interview was conducted with EI #7, the Administrator/Abuse Coordinator. EI #7 was asked when he was notified of the alleged abuse involving RI #s 54, 94, and 2. EI #7 answered he was notified on the afternoon of Saturday, (MONTH) the 13 th, around 3 p.m EI #7 was asked what information was reported to him related to the alleged abuse. EI #7 responded it was reported to him that RI #2 was seated in a common area and RI #54 was attempting to leave that common area. RI #54 was moving past RI #2. RI #2 failed to move to allow passage, RI #54 struck RI #2 upon the head and face with an open hand. RI #94 was in the same area and was hit about the same time with an open hand. EI #7 was asked when and what actions were taken to protect the alleged victim from further abuse while the investigation was in process. EI #7 responded the aggressor was removed by staff to his/her room with a CNA, (EI #6), assigned to stay with her/him. Both victims (EI #2 and EI #94) were assessed for visible injury and queried (questioned). EI #7 was asked who he notified of the alleged abuse. EI #7 responded ADPH (Alabama Department of Public Health) via (by) the online reporting system. EI #7 was asked when he made the notification. EI #7 answered on 1/13/18 at 5:11 p.m EI #7 was asked if an outside entity was informed about the alleged abuse and he answered no. EI #7 was asked who was responsible for the investigation and he answered he was. EI #7 was asked if the investigation was completed or ongoing. EI #7 stated it was complete. EI #7 was asked what was the outcome. EI #7 answered his conclusion was that no abuse occurred. EI #7 stated, However, I came to that conclusion 1. because there was no obvious injury. 2. there was no confinement or punishment. EI #7 was asked when and what actions were taken to protect the alleged victim and residents at risk from further abuse while the investigation was in process. EI #7 reported RI #94 was removed from the secured unit, RI #2 was provided alternative seating in the common area, and RI #54 was transferred for evaluation and treatment outside the facility. EI #7 was asked what was the definition of physical abuse and he answered physical abuse includes hitting, slapping, pinching, kicking, etc (etcetera). EI #7 was asked if any of those occurred and he answered yes. EI #7 was asked why the allegation was not substantiated. EI #7 referred to his earlier conclusion of his investigation. EI #7 was asked what was the concern of not substantiating an allegation of abuse that investigations did substantiate. No answer was given. This deficiency was cited as a result of the investigation of complaint/report #AL 601. |
2020-09-01 |