| 63 |
HAVEN OF SCOTTSDALE |
35059 |
3293 NORTH DRINKWATER BOULEVARD |
SCOTTSDALE |
AZ |
85251 |
2019-01-25 |
607 |
D |
0 |
1 |
NNTV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their abuse policy, by failing to identify an incident of neglect involving a staff member and a resident (#8), and by failing to report the incident of neglect to the State Agency and Adult Protective Services (APS). The resident census was 41. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The resident was placed on Alert Charting, the care plan was updated and a Fall Risk Assessment was completed. The physician and responsible party were notified. A physician hospital progress note dated 11/16/2018 included the resident was admitted due to being transferred from the wheelchair to standing, and while standing fell out of their grasp. Patient reports the staff person lost their balance while standing, and fell on to the patient. The hospital course included the resident had a humeral head fracture status [REDACTED]. Further review of the investigative documentation revealed the facility had not identified this incident as neglect, therefore, did not notify the State Agency and APS. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated the types of abuse staff are trained on include physical, emotional, mental, sexual, financial, verbal and neglect. Regarding allegations of abuse/neglect, he stated they initiate an investigation and the leadership team will make a determination on whether or not it is abuse. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not provided. He stated the CNA (staff #67) was terminated, because he did not follow the resident's care plan and our policy regarding transfers. Staff #40 also stated that staff members have been educated that they have to call the State Agency, along with other agencies within 2 hours of becoming aware of the incident. An interview was conducted on 1/25/19 at 9:38 a.m. with staff #29, who stated that based on the definition of neglect as discussed (above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the Director of Nursing (DON/staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed (above) she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67) who transferred the resident. He stated the facility policy was to use a gait belt for all transfers. He said that he used a gait belt for all transfers, except for one incident when resident #8 fell . Staff #67 stated he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. Review of the facility's Abuse policy revealed the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. We care for residents with a [DIAGNOSES REDACTED]. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 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. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy included that if abuse is witnessed or suspected, reporting and an investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: a. Adult Protective Services b. Ombudsman 3. State Survey Agency d. Law Enforcement when applicable e. Facility Director of Nursing (DON) 3. DON will notify the following: a. Physician b. Responsible Party c. Corporate Clinical Team 4. ED will begin investigation immediately and complete within 5 days using the Abuse Investigation Packet. Suspected abuse will be reported in accordance with timeframes and standards required by the State Agency. If an employee is suspected of being the abuser, they will be suspended until the investigation is complete. If the investigation finds that abuse is substantiated and the abuser is an employee, they will be immediately terminated and licensure reporting as applicable will be done. The policy further included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse. |
2020-09-01 |