| 67 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2020-01-24 |
607 |
J |
1 |
0 |
17111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review and facility policy review, the facility failed to implement their Abuse policy for protection of residents from verbal abuse, failed to protect other residents, and failed to report the allegation of abuse in a timely manner, for one (1) of seven (7) residents, Resident #1. This was evidenced by the facility allowing Certified Nursing Assistant (CNA) #1 to return to work following an incident of witnessed verbal abuse toward Resident #1. The facility failed to report the allegation of abuse to the required state agencies within the two (2) hour timeframe, per policy, to ensure appropriate actions were taken. On [DATE], CNA #1 was witnessed being verbally abusive to Resident #1 in the dining room, by staff members. CNA #1 was overheard 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 same day of the incident. LPN #2 reported the incident to the Director of Nursing (DON), who then informed LPN #2 to assign CNA #1 to a different hall, and for CNA #1 not to have any contact with Resident #1. CNA #1 was allowed to continue working on [DATE], and provided care to Resident #1's roommate, Resident #7. CNA #1 continued 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 in a timely manner and failed to protect Resident #1 and all other residents. The failure of the facility to protect residents from verbal abuse by allowing a staff member to remain working at the facility, and failure to report an incident of witnessed verbal abuse within to two (2) hours to the designated State Agencies, per facility policy, 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(b)(1)-(3), F[AGE]7, Develop/Implement Abuse/Neglect Policies 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. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, serving the resident. The facility's goal is to protect the resident from abuse. The facility has developed and implemented written policies and procedures designed to prohibit and prevent mistreatment. The prohibition plan includes the following components: Screening prospective employees, staff training, abuse and neglect prevention, identification of events, patterns or trends that may constitute abuse, investigation of allegations, protecting of the resident during investigations, reporting and responding. The facility will report alleged violations, conduct investigations of alleged violations, report the results to proper authorities, and take necessary corrective actions. 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 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 wheelchair, 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 was given instructions for CNA #1 to be reassigned to another hall, and to have no contact with Resident #1 until further notice. The investigation report documented the actions taken by the facility included a visit by the Social Worker and Nurse Practitioner with Resident #1 on 12/23/2019, in-services initiated with staff regarding abuse policy and prevention on 12/24/2019, and the Administrator reviewed CNA #1's personnel file and background. There was no documentation of CNA #1 being suspended or sent home on the day of the incident ([DATE]). During an interview, on 01/21/2020 at 10:30 AM, the Administrator stated if she had known the detailed statements regarding the incident on [DATE] between CNA #1 and Resident #1, she would have suspended CNA #1. The Administrator stated it is the facility's policy to protect residents immediately. Upon review of the facility's Abuse policy, the Administrator stated they didn't follow the policy for reporting abuse. Review of the facility's Job Description for the Nursing Home Administrator (NHA), revealed: The NHA is responsible for the overall operations, leadership, management and success of the facility. Essential duties and responsibilities included to implement and communicate policies and procedures and oversee facility investigations and [MEDICATION NAME]. During an interview, on 01/21/2020 at 12:15 PM, Resident #1 revealed on [DATE], he was having a conversation with another resident and CNA #1 was all up in his business. Resident #1 stated he told CNA #1 to get the hell out of his business. Resident #1 stated CNA #1 went over to the kitchen door, and he heard her call him a Mother [***] . Resident #1 stated the Dietary Manager was standing right beside CNA #1 when she said it. Resident #1 stated he nor his mother was a Mother [***] and nobody was going to call him by that name. Resident #1 stated CNA #1 also called him a Son of a [***] . Resident #1 revealed he never threatened to hit CNA #1, but was upset when she called him those names. During an interview, on 01/21/2020 at 12:38 PM, the Director of Nursing (DON) stated the facility did not follow the policy to protect Resident #1 when CNA #1 was not sent home for cursing Resident #1. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 confirmed that on the day of incident, she told Resident #1, Don't put your mother [***] ing hands on me. CNA #1 stated she told the Administrator on 12/23/2019 that she had cursed Resident #1. CNA #1 stated that she stayed on the 100 Hall on 12/21/19 and took care of Resident #7 (Resident #1's roommate). CNA #1 stated she saw Resident #1 probably three (3) more times after the incident in the dining room. CNA #1 stated Resident #1 was in the room when she went in to do patient care with Resident #7, but she left and came back when Resident #1 was gone from the room. A review of the time sheet for CNA #1 revealed she worked in the facility 12/21/19, 12/22/19 and [DATE]. A review of the facility scheduling document dated 12/21/19 revealed CNA #1 was assigned to resident rooms on the 100 Hall, which included Resident #1's room. During an interview, on 01/21/20 at 2:30 PM, the Administrator stated that she did not call the allegation of verbal abuse into the State Survey Agency until [DATE], after she started the investigation. The Administrator stated she thought she had 24 hours to report since there was no known injury. She stated she did not know she had to report an alleged abuse within two (2) hours. The Administrator revealed she did not report the incident of abuse to any local Law Enforcement Authority. She stated she called the incident of abuse to the State Survey Agency on 12/23/2019, to the Attorney General's Office (AG) on 12/30/2019 and mailed the final investigation information to the AG's office and to the State Agency on 1[DATE]. The facility submitted an acceptable 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 |