cms_AZ: 99
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 99 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2018-03-30 | 607 | D | 1 | 1 | WXKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to implement their Abuse policy regarding four residents (#18, #49, #58 and #74). Findings include: -Resident #49 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. -Resident #74 was admitted on (MONTH) 23, 2012, with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 20, (YEAR), resident #49 got up from his chair in the unit dining room and walked over to where resident #74 was seated, and slapped resident #74 on the face. Further review of the facility's investigative report revealed a statement from a staff member who had witnessed the incident, however, there were no statements from other staff and there was no documentation that resident #49 or #74 were interviewed regarding the incident. An interview was conducted with the DON (Director of Nursing/staff #18) on (MONTH) 27, (YEAR) at 12:42 p.m. Staff #18 stated that he did not interview other staff who may have witnessed the incident between resident #49 and resident #74. In a later interview on (MONTH) 27, (YEAR) at 2:16 p.m., staff #18 stated that he did not interview resident #49 or #74, due to the resident's having cognitive impairment. -Resident #18 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility's investigative documentation revealed that on (MONTH) 26, (YEAR), a Certified Nursing Assistant (CNA) was providing care to the resident in his room. The CNA called for help and staff assisted the CN[NAME] The resident was observed to be bleeding from a laceration above his eyebrow. When questioned, the CNA stated that the resident had started to become combative during care and was swinging and hit himself in the head, causing the laceration. Further review of the investigative documentation revealed it did not include interviews with other residents, who may have been cared for by this CN[NAME] An interview was conducted with staff #18 at 7:45 a.m. on (MONTH) 28, (YEAR). He said that he was involved in the investigation of this incident and that normally as part of the investigation, they will interview residents who may have received care by the alleged perpetrator. He stated that he thought this had happened for this incident. He said that sometimes the social worker conducts the interviews with the residents. In an interview with the social service director (staff #16) at 8:50 a.m. on (MONTH) 28, (YEAR), he said that he did not interview residents regarding this incident. He said that a few years ago, he used to be more involved in the investigations, but now he does not get very involved in them. During another interview with staff #18 at 1:00 p.m. on (MONTH) 29, (YEAR), he said that he did not locate any interviews with other residents and that this should have been done, as per facility policy. -Resident #58 was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A behavior note dated (MONTH) 21, (YEAR) at 9:35 a.m. revealed this writer heard yelling down the hallway and entered the resident's room. The resident was squirming around in her bed, as a CNA (staff #33) was attempting to dress her following a shower. Per the note, the resident stated, she hit me in the face, she's going to be fired. There was no redness, swelling or any injury to the face. The note further included the CNA had stated that the resident hit her and she denied hitting the resident. Review of the facility's investigation revealed that on (MONTH) 21, (YEAR), a licensed practical nurse (staff #54) heard yelling from resident #58's room. Staff #54 entered the resident's room and staff #33 was inside. The resident told staff #54 that staff #33 had hit her in the face. Upon assessment, staff #54 reported that there were no signs of injury. Staff #33 denied striking the resident. Further review of the facility's investigative report revealed there was no documentation that resident #58 was interviewed or that other resident's were interviewed who may have been provided care by this CN[NAME] An interview was conducted with staff #18 on (MONTH) 28, (YEAR) at 12:45 p.m. He stated that he did not have any documentation that the resident was interviewed during the investigation. Review of the facility's Abuse policy revealed that all allegations and signs of resident abuse, neglect and injuries of unknown source shall be immediately reported and thoroughly investigated by facility management. The policy also included that the individual conducting the investigation at a minimum will interview the resident, the resident's roommate, interview other residents to whom the accused employee provides care or services, and interview all staff members who have had contact with the resident(s) during the period of the alleged incident. | 2020-09-01 |