| 68 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2020-01-24 |
609 |
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 report an allegation of staff to resident abuse within the two (2) hour required timeframe, for one (1) of seven (7) residents reviewed, 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 witnessed incident of verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The facility's failure to notify the appropriate state agencies in a timely manner of an incident of witnessed verbal abuse, to ensure proper measures had been addressed, and allowing the staff member to continue working at the facility, 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(c)(1)(4), F[AGE]9, Reporting of Alleged Violations, 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: Review of the facility's Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan - Reporting/Response policy, revised 08/23/2017, revealed: If a covered individual of the facility becomes aware of information that gives him/her the reasonable suspicion that a crime has occurred against a resident or individual receiving care from this facility, he/she must notify the Administrator of the facility, the State Survey Agency and Attorney General's Office, and local Law Enforcement Agency. Reports must be within two (2) hours (if the allegation involves abuse or there is serious bodily injury) after forming reasonable suspicion. A review of an on-line submission record, sent to the Medicaid Fraud Control Unit (MFCU), revealed the Administrator submitted the report, on 12/30/2019, regarding the alleged verbal abuse incident, which occurred on [DATE]. Review of a facility reported incident to the State Agency, submitted on 01/06/2020, revealed an incident of verbal abuse occurred at the facility on [DATE], between CNA #1 and Resident #1. A review of a typed document, undated and signed by the Administrator revealed, the incident of verbal abuse, which occurred on [DATE], was reported to the Mississippi State Department of Health ([CONDITION]DH) hotline on 12/23/2019. The final investigative report was mailed to [CONDITION]DH and the Attorney General's Office on 1[DATE]. The State Agency (SA) confirmed via phone interview with SA Triage office, the Administrator reported the verbal abuse incident, which occurred on [DATE], on 12/23/2019. During an interview, on 01/21/2019 at 2:30 PM, the Administrator stated she did not call the incident of verbal abuse (which occurred on [DATE]), into the State Survey Agency until 12/23/2019, after she started the investigation. The Administrator stated she thought she had 24 hours to report the incident, since there was no known injury. The Administrator revealed she did not know an incident of alleged abuse had to reported within two (2) hours. During an interview, on 01/22/2020 at 12:14 PM, the Administrator revealed she did not report the incident to any local Law Enforcement Authority. The Administrator stated that she called the incident of verbal abuse to the State Survey Agency on 12/23/2019, and to the Attorney General's (AG) Office on 12/30/2019. The Administrator stated she mailed the final investigation information to the AG's office and State Agency on 1[DATE]. A review of the facility's Job Description for the Nursing Home Administrator (NHA), dated 08/10/2017, revealed: The NHA will be responsible for the overall operations, leadership, management and success of the facility in accordance with resident/employee needs, government regulations, and company policy. Essential duties and responsibilities included, to oversee facility investigations and [MEDICATION NAME], and to carry out supervisory responsibilities in accordance with the organizations policies and applicable laws. 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 |