cms_ID: 82
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 82 | GATEWAY TRANSITIONAL CARE CENTER | 135011 | 527 MEMORIAL DRIVE | POCATELLO | ID | 83201 | 2019-04-12 | 585 | D | 1 | 1 | WTPU11 | > Based on record review, policy review, resident, resident representative, and staff interview, it was determined the facility failed to document, investigate, and report complaints expressed by 1 of 19 residents (Resident #227) whose complaints were reviewed. This failure created the potential for harm if residents' verbal grievances were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect. Findings include: The facility's Grievance Policy, dated 1/2018, documented residents had the right to file a grievance orally or in writing and the right to obtain a review in writing; and when a grievance was voiced to a staff member a grievance form would be completed and the grievance would be evaluated and investigated. The facility's Grievance file did not include a grievance for Resident #227. On 4/10/19 at 9:56 AM, Resident #227 and his representative stated they reported incidents to the facility staff, as well as other concerns that were medical in nature, as follows: - A nurse answered the call light and said she could not help Resident #227 but was going to get a CNA to help. The CNA never came, and Resident #227 had to sit in urine and feces for an extended period of time causing skin issues in his peri-area. - A nurse yelled at Resident #227 and chewed him out when his representative called the DON to complain about the care the nurse had given to Resident #227. The representative said she used her cell phone and a land line phone to connect the DON directly to Resident #227's room so the DON could hear the way Resident #227 was treated by a particular nurse. - Resident #227 received rough care by a CNA who had transferred him, unassisted, using a Hoyer lift (a mechanical lift). During the transfer, Resident #227 was bumped against the Hoyer lift and the foot board of the bed which caused damage to his knee, which was the site of a recent surgical procedure. Resident #227 reported the same CNA picked up his leg, jerked the stump away from his body and dropped his stump on the bed causing extreme pain. Resident #227 said this same CNA also positioned his urinal in a rough manner, which caused him pain. On 4/9/19 at 11:09 AM, the DON said he had not documented the complaints made by Resident #227 and said Resident #227 was very particular in his care needs. The DON said when Resident #227 made complaints, the staff tried to meet his needs. The DON recalled the partial conversation he overheard by phone between Resident #227 and the nurse, and said he could not substantiate that abuse had occurred. The DON said he had not conducted a formal investigation into the nurse's behavior but had reassigned the nurse to prevent other complaints and incidents. The DON said he had not documented any of the incidents reported by Resident #227, nor had he documented the resolution of the complaints and he was not aware of some of the complaints. The DON said he had responded to several complaints by the resident but had not felt the complaints had risen to the level of abuse or neglect. The facility failed to provide documented evidence Resident #227's concerns reported by him and/or his representative were investigated, reported, and acted upon. | 2020-09-01 |