| 66 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2020-01-24 |
600 |
J |
1 |
0 |
17111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of seven (7) residents reviewed for abuse, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely, and failed to protect Resident #1 and all other residents. The facility's failure to protect Resident #1 from verbal abuse and allowing a staff member to work in the facility, without reporting an incident of witnessed verbal abuse, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Therefore, the scope and severity for 43 CFR(s): 4[AGE].12(a)(1), F[AGE]0, Freedom from Abuse, Neglect, and Exploitation, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy, undated, revealed: The resident has the right to be free from abuse. The policy defined Verbal Abuse as the oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. A review of the facility's Resident Rights policy, dated November 28, 2016, revealed: The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Review of a facility reported incident, submitted to the SA on 01/06/2020, documented on [DATE], CNA #1 verbally abused Resident #1. The report included a typed investigation, on the facility's letterhead, dated 1[DATE] and signed by the Administrator. The investigation documented on [DATE], Licensed Practical Nurse (LPN) #1 reported to the on-call nurse (LPN #2), an incident involving a verbal altercation between Resident #1 and CNA #1, which occurred in the dining room. The report documented LPN #1 stated Resident #1 became upset with CNA #1 about his meal, stood up from his chair, and yelled, I am going to beat your mother [***] ing ass. LPN #1 reported CNA #1 responded, You're not going to put your mother[***] ing hands on me. The investigation documented LPN #2 notified the Director of Nursing (DON) and gave instructions for CNA #1 to be reassigned and have no contact with Resident #1 until further notice. The investigation documented on 12/23/2019, the DON interviewed the Dietary Manager (DM), who witnessed the exchange between Resident #1 and CNA #1 on [DATE]. The DM reported CNA #1 entered the kitchen and told him that he needed to talk with Resident #1 about his meal. The DM further reported he asked CNA#1 what was the issue with Resident #1's meal, and she stated, Something isn't right with it, just his usual bullshit. I ain't got time to deal with his[***]today. The DM reported Resident #1 approached CNA #1 and told her You need to shut your [***] ing mouth and get the [***] out of my face. I'll whoop your ass. The DM reported CNA #1 responded, Mother [***] put your hands on me and watch what happens. The DM reported he asked another CNA to get the nurse while he redirected Resident #1 and CNA #1. The investigation report documented actions taken by the facility included Resident #1 was visited by the Social Worker and Nurse Practitioner on 12/23/2019, in-services initiated to staff regarding abuse policy and prevention on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. A review of a typed statement by the Dietary Manager, dated and signed 12/23/2019, documented that on [DATE] at approximately 7:55 AM, the DM witnessed the incident between CNA #1 and Resident #1. The DM revealed CNA #1 came to the kitchen door to tell the dietary staff of an issue regarding Resident #1's meal. The DM documented CNA #1 stated loudly (within the presence of residents and staff), Something isn't right with it, just his usual bullshit, I ain't got time to deal with his[***]today. The DM documented Resident #1 approached CNA #1, in his wheelchair, and told her to shut your [***] ing mouth and I'll whoop your ass. The DM further documented, CNA #1 had her hands in fists at her sides, and stated to Resident #1, Mother[***] , put your hands on me and watch what happens. The DM revealed he intervened by stepping between Resident #1 and CNA #1, and instructed Resident #1 to return to his table and for CNA #1 to leave the dining room immediately. The DM revealed he asked another CNA to get a nurse to the dining room immediately. The DM documented when LPN #1 entered the dining room, he informed her of the situation, how it started, and what was said by Resident #1 and CNA #1. During an interview, on 1/21/2020 at 10:30 AM, the Administrator stated what she understood was when the incident occurred on [DATE], LPN #2, the on-call nurse, called the Director of Nursing (DON) to report the incident. The Administrator revealed the DON was informed CNA #1 told Resident #1, You're not going to put your mother [***] ing hands on me. The Administrator stated at the time of the incident, they needed more information about what happened and didn't know all the details. She revealed she needed to get further clarification, before coming to a conclusion, regarding the incident. The Administrator stated she believed at the time of occurrence, they removed CNA #1 from Resident #1, placed her on another hall in the building, thus protecting Resident #1. During an interview, on 01/21/2020 at 12:15 PM, Resident #1 revealed on [DATE], he was sitting in the cafeteria waiting on his breakfast tray and having a conversation with another resident. Resident #1 stated CNA #1 was all up in his business, and he told her to get the hell out of his business. Resident #1 stated CNA #1 went in the kitchen door and he heard her call him a Mother [***] . Resident #1 stated the man in charge of the kitchen (Dietary Manager) was standing right beside CNA #1 when she said that to him. Resident #1 stated he and his mother were not a Mother [***] and nobody was going to call him by that name. Resident #1 stated he also heard CNA #1 call him a Son of a [***] . Resident #1 stated he never threatened to hit CNA #1, but was just upset when she called him those names. Resident #1 stated when he heard what CNA #1 had called him, it made him feel damn low down. On 01/21/2020 at 12:38 PM, during an interview, the DON stated she received a call from LPN #2, on [DATE], regarding an incident in the dining room between Resident #1 and CNA #1, where they had cussed at each other. The DON stated she informed LPN #2 to tell LPN #1 for CNA #1 not to have any further contact with Resident #1. The DON revealed that was the last thing she heard about the issue until she returned to the facility on [DATE]. The DON stated she didn't think much about it, because it wasn't unusual for Resident #1 to curse staff, but it was uncommon for staff to curse him back. The DON stated after reading the written statements, when she returned on 12/23/2019, she realized that she should have sent CNA #1 home on [DATE]. The DON stated she would consider the incident to be verbal abuse. During a telephone interview, on 01/21/2020 at 1:00 PM, LPN #2 confirmed she was the on-call nurse on [DATE]. LPN #2 stated LPN #1 called and told her Resident #1 was in the dining room threatening CNA #1. LPN #2 stated LPN #1 told her Resident #1 stood up from his wheelchair and stated he was going to whip CNA #1's mother [***] ing ass. LPN #2 revealed LPN #1 further stated CNA #1 told Resident #1 he was not going to lay a mother [***] ing hand on her. LPN #2 stated she instructed LPN #1 to get CNA #1 to swap out residents with another CNA, and CNA #1 was not to have any contact with Resident #1. LPN #2 stated she called the DON and told her exactly what LPN #1 told her regarding the incident. LPN #2 revealed the DON instructed her to tell LPN #1 to swap CNA #1 out with another CNA taking care of Resident #1 as well. LPN #2 stated that she felt like CNA #1 cursing Resident #1 was considered verbal abuse. LPN #2 revealed the facility's policy stated it's not acceptable for staff to curse a resident. LPN #2 stated she felt the right decision was made on [DATE] when they moved CNA #1 away from Resident #1 until a thorough investigation could be done. During an interview, on 01/21/2020 at 2:45 PM, the Dietary Manager (DM) confirmed he was working the day of the incident ([DATE]). The DM stated Resident #1 was sitting in his normal place, when CNA #1 came to the kitchen door and said y'all need to talk to Resident #1 about his breakfast. The DM stated he asked CNA #1 what was wrong with Resident #1's breakfast and she stated just Resident #1 and his bullshit. The DM revealed what CNA #1 said, was loud enough to be heard by Resident #1. The DM revealed he saw Resident #1 push back from the table and start rolling in his wheelchair towards the kitchen door where CNA #1 was standing. The DM stated when Resident #1 approached CNA #1, Resident #1 told CNA #1 she needed to shut her [***] ing mouth and didn't need to be talking about him or he was going to whip her [***] ing ass. The DM stated he saw CNA #1 ball her fists up, but kept them at her side. The DM stated CNA #1 told Resident #1, Look here you mother [***] ing son of a [***] , if you come towards me, I'll knock you the [***] out. The DM stated he intervened and separated Resident #1 and CNA #1. The DM revealed he instructed CNA #1 to leave the dining room immediately, but she refused. The DM stated when CNA #1 refused to leave the dining room, he instructed another CNA in the dining room, to go and get a nurse. The DM revealed he instructed Resident #1 to go back to his table. The DM stated LPN #1 came to the dining room, and he pulled her aside and told her about the incident between Resident #1 and CNA #1. During an interview, on 01/21/2020 at 3:11 PM, CNA #2 stated that she was in the dining room, passing out meal trays, on [DATE], when the incident happened between Resident #1 and CNA #1. CNA #2 stated Resident #1 opened his tray up and said, I don't want this[***] and slid the tray across the table. CNA #2 stated she heard CNA #1 tell someone in the kitchen that they needed to come and see what was wrong with Resident #1's tray. CNA #2 stated Resident #1 was sitting at the table and suddenly pushed back and rolled to the kitchen door where CNA #1 was standing. CNA #2 stated told CNA #1, I heard what you said twice, along with a bunch of cuss words. CNA #2 revealed Resident #1 stood up from his wheelchair and stood over her (taller than CNA #1) and told CNA #1 he would beat her ass. CNA #2 stated she ran over to Resident #1 and intervened by telling the resident no and tried to assist him back into his wheelchair. CNA #2 stated CNA #1 told Resident #1, If you put your hands on me today, I'm going to box your ass. CNA #2 stated the Dietary Manager came out of the kitchen and told Resident #1 to go back to his seat. CNA #2 confirmed the Dietary Manager told CNA #1 to leave the dining room. A review of a written statement given by CNA #2, undated and provided by the facility, CNA #2 documented on 12/21/19 she heard CNA #1 curse Resident #1. The statement documented CNA #1 told Resident #1, (Name of Resident #1) if you put your hands on me, I will box your mother [***] ing ass. During an interview via phone on 1/21/20 at 4:29 PM, LPN #1 stated that Resident #1 and CNA #1 were in the dining room and she was called to the dining room by another CNA, who stated Resident #1 was threatening CNA #1. LPN #1 stated when she arrived, the Dietary Manager was talking to Resident #1. LPN #1 stated she noticed Resident #1 and CNA #1 were upset. LPN #1 stated CNA #1 told her Resident #1 had threatened to hit her. LPN #1 stated she told CNA #1 to come out of the dining room and she sent another CNA to the dining room to take CNA #1's place. LPN #1 revealed CNA #1 told her that Resident #1 didn't like what he got on his tray, got upset and threatened to hit her. LPN #1 stated she called the on-call phone nurse, LPN #2, and told her about the incident in the dining room with Resident #1 and CNA #1. LPN #1 stated LPN #2 told her to get CNA #1 out of the dining room and that she would call either the Administrator or the Director of Nursing (DON). LPN #1 stated she couldn't remember who called her back, but she was told to make sure CNA #1 didn't have any contact with Resident #1. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 stated the incident with Resident #1 occurred on a weekend (Saturday, [DATE]). CNA #1 stated Resident #1 was in the dining room at breakfast, and he started fussing and cursing. CNA #1 stated she told him if he didn't stop, he would have to leave the dining room. CNA #1 stated she went to the kitchen to see about oatmeal for another resident and told the Dietary Manager to come and talk to Resident #1 because he was fussing about his food. CNA #1 stated while her back was turned, Resident #1 came over in his wheelchair, stood up and stated, I'm fixing to beat this black [***] . CNA #1 stated she told Resident #1, Don't put your mother [***] ing hands on me. CNA #1 confirmed CNA #2 came over, got between them, and tried to get Resident #1 to sit down in his chair. CNA #1 stated the Dietary Manager told her to get out of the dining room and that she couldn't talk to a resident like that. CNA #1 stated she told the Dietary Manager that Resident #1 was about to hit her, and she felt threatened. CNA #1 stated the Dietary Manager told her twice to leave the dining room, but she refused because she hadn't done anything. CNA #1 stated she left the dining room and told LPN #1 what had happened. CNA #1 revealed LPN #1 told her she was going to have to call the on-call nurse (LPN #2). CNA #1 stated LPN #2 called back and instructed LPN #1 to have her stay away from Resident #1. CNA #1 stated she continued to work on the hall, on [DATE], where Resident #1 resided and cared for Resident #1's roommate (Resident #7), who was non-verbal. CNA #1 stated if Resident #1 was in the room, she would leave and return when he wasn't present in the room. CNA #1 stated on 1[DATE]19, LPN #2 called the facility and told her not to work the dining room since Resident #1 ate in there. CNA #1 stated she was called to the Administrator's office on 12/23/2019 to discuss what had occurred on [DATE] with Resident #1 and to write a statement. CNA #1 stated she told the Administrator that she did curse Resident #1, even if it costed her job. A review of the Activity of Daily Living (ADL) look back report for Resident #7, who was Resident #1's roommate, revealed, CNA #1 provided care for Resident #7 on 12/21/19 at 10:44 AM. Care was provided after the incident in the dining room with Resident #1. Review of the time sheet for CNA #1, revealed she clocked in for work at the facility on [DATE], 1[DATE]19, and 12/23/2019. A review of the facility's Job Description for a Certified Nursing Assistant (CNA), signed on 06/17/19 by CNA #1, revealed: Assist in maintaining a positive physical and psychosocial environment for the residents. Essential duties and responsibilities included to maintain positive relationships with the residents. Review of the personnel file for CNA #1 revealed, a copy of the facility's Freedom for Abuse, Neglect, and/or Exploitation Prevention Plan Education, dated 06/17/2019 and signed by CNA #1. There were no prior discipline records noted. Review of a Sign In Sheet for an in-service, on Abuse and Neglect Prevention, dated 10/03/ , revealed CNA #1 signed as being in attendance. During an interview, on 01/22/2020 at 10:54 AM, the Administrator stated she felt like CNA #1 verbally abused Resident #1. On 01/22/2020 at 12:31 PM, during an interview, the DON stated she felt that CNA #1 cursing Resident #1 was verbal abuse, and she should have sent CNA #1 home pending further investigation. The DON stated she did not protect Resident #1 or any of the other residents by not sending CNA #1 home. A review of a typed statement by the DON, dated 12/23/2019, documented during an interview with CNA #1, she stated she had cursed Resident #1. During an interview, on 01/22/2020 at 3:15 PM, CNA #3 stated she was in the dining room on [DATE]. CNA #3 stated she heard CNA #1 tell Resident #1 not to put his mother [***] ing hands on her. CNA #3 stated the Dietary Manager came out of the kitchen and told CNA #1 to leave the dining room because she didn't have any business talking to Resident #1 like that. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated cognitively intact. The facility submitted a credible Removal Plan on 0[DATE]20, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. 1. Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. On [DATE]20 100% of facility residents were assessed by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The Facility Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. A meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. On 12/30/2019, The Attorney General Office online report was submitted by the Facility Administrator. 7. On 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. On 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. On 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed and the jeopardy abated as of 0[DATE]20. The SA validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The State Agency (SA) validated through record review, Resident #1 was assessed by the Psychiatric Nurse Practitioner on 12/23/2019 with no adverse findings noted related to the verbal abuse that occurred on [DATE]. LPN #3 completed a head to toe body audit on Resident #1 on [DATE]19 and noted no signs of physical abuse. The SA validated through record review, that on 0[DATE]20, a 100% assessment of facility residents by the DON, Assistant DON, MDS Nurse, LPN # 4 and RN # 1 with no signs and symptoms of abuse noted. The Social Service Director (SSD) and Admission Social Services interviewed 100% of interviewable residents regarding abuse with no reports of abuse received on 0[DATE]20. 2. The SA validated through interview and record review, the Administrator provided initial notification to the [CONDITION]DH telephone hotline on 12/23/2019 of the verbal abuse that occurred on [DATE] to Resident #1. 3. The SA validated through interview and record review, a meeting was held with the DON, SSD and Administrator regarding verbal abuse, reporting of abuse and in-service training of direct care staff on abuse and reporting requirements. 4. The SA validated through interview and record review, the Administrator, SSD, DON and Assistant DON initiated in- service training for 100% of direct care staff on 12/24/2019 regarding the abuse policy, types of abuse, protection of the resident, reporting allegations of abuse immediately to supervisor, DON and Administrator and suspension of employee accused immediately. In-service training ended on 0[DATE]20. No staff, including new hires, will be allowed to work at the facility prior to receiving in-service training with understanding expressed by the staff member. 5. The SA validated through interviews and record review, a Quality Assurance and Performance Improvement (QAPI) meeting was held on 12/31/2019 with the SSD, Facility Administrator, Medical Director, Admission Social Services, Care Plan Nurse, LPN #2 and Infection Preventionist/ Assistant Director of Nursing. The incident of verbal abuse that occurred on [DATE] and the abuse policy and procedures were reviewed. The Committee agreed upon providing in-service training for all direct care staff regarding abuse policy, types of abuse, reporting of abuse to supervisor, DON and Administrator, protection of resident and immediate suspension of employee accused of abuse. 6. The SA validated through record review, on 12/30/2019, the Attorney General Office online report was submitted by the Facility Administrator. 7. The SA validated through interview and record review, on 01/22/2020, the Regional Director of Operations (RDO) in-serviced the Facility Administrator and the DON regarding reporting allegations or instances of abuse within the two (2) hour time frame per regulation. 8. The SA validated through interview and record review, on 01/22/2020, the Facility Administrator in-serviced the DON regarding reporting any allegations of abuse to the Facility Administrator immediately at the time of occurrence and counseled on failure to report the allegation. 9. The SA validated through interviews and record review, on 01/22/2020, an Emergency QAPI meeting was held with the Medical Director and the QAPI team including the MDS Nurse, Registered Nurse (RN) #1, Maintenance Director, Life Connections Coordinator, SSD, Infection Preventionist, DON, Admission Social Services, DM, Business Office Manager, Human Resources Representative, Administrator and Housekeeping Supervisor. The IJs were discussed and the Abuse policy was reviewed. It was determined that the Abuse Policy was not followed for the incident that occurred on [DATE] therefore no policy changes were recommended. 10. The facility alleges that all corrective actions have been completed as of 0[DATE]20, and the IJ removed as of 01/24/2020. |
2020-09-01 |