| 78 |
DESERT HAVEN CARE CENTER |
35062 |
2645 EAST THOMAS ROAD |
PHOENIX |
AZ |
85016 |
2020-01-08 |
610 |
D |
1 |
0 |
DWKV11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that an allegation of resident to resident abuse for two residents (#1, 2) was thoroughly investigated. The deficient practice could result in additional allegations of abuse not being thoroughly investigated by the facility. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. The note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 stated that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. two CNA's (Certified Nursing Assistants) witnessed an altercation, and that the staff stated that resident #1 entered resident #2's room (located on the Magnolia Unit) and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. The report included that the staff who were present immediately separated the resident's, the residents were assessed for injuries, and there were no injuries present. Review of the facility investigation, did not incude any direct witness statements, or reveal the names of the two CNA's who witnessed the altercation, or identify the staff who separated residents #1 and #2. The following interviews were conducted on (MONTH) 7, 2020 with the following staff who were assigned to the Magnolia Unit on (MONTH) 21, 2019 when the incident occurred: -At 10:00 a.m. a CNA/staff #86 stated that when the incident occurred she was not present on the unit at that time because she was on a break and that she believed that two other CNA's (staff #173, and #71) and a nurse (staff #21) remained on the unit while she was on break. -At 10:09 a.m. a CNA/staff #143 stated that she did not witness what actually happened because she was in another room with another CNA (staff #71) providing care to a resident. Staff #143 stated she heard a commotion and when she went out of the room saw resident #1 placing resident #2's pet birds in the hallway, the two resident's were arguing and she helped to separate them. Staff #143 stated that another CNA was supposed to be monitoring the hallway while she and staff #71 were in another room providing care, and she did not know the location of the nurse at the time of the incident. -At 10:22 a.m. a CNA/staff #71 stated she did not observe what happened because she was assisting staff #143 to provide care in another room when the incident occurred. Staff #71 stated that there should have been a nurse and at least one of possibly two CNA's on the unit when she was in another room providing care. -At 11:35 a.m. an LPN/staff #21 stated that when the incident occurred she was off the unit on a break and did not witness the incident. The following interviews were conducted on (MONTH) 7, 2020 with the Director of Nursing/staff #120: -At 9:00 a.m. the Director identified 3 CNA's who were assigned to work on the Magnolia Unit on (MONTH) 21, 2019 at the time of the incident, and stated that witness statements had not been obtained from the CNA's. -At 10:26 a.m. the Director identified a nurse who was assigned to work on the Magnolia Unit on (MONTH) 21, 2019 at the time of the incident, and stated that witness statements had not been obtained for this investigation. A policy and procedure titled Abuse Investigations included a statement that all allegations/signs of resident abuse, neglect and injuries of unknown source shall be thoroughly investigated by facility management, and that the Administrator or his/her designee will appoint a member of management to investigate the alleged incident. The policy included that the individual conducting the investigation will, as a minimum interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident and the witness reports will be obtained in writing. |
2020-09-01 |