| 69 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2020-01-24 |
610 |
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 prevent further potential abuse and mistreatment from occurring, after a witnessed incident of staff to resident abuse, 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 (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 thoroughly investigate a witnessed staff to resident incident of verbal abuse, and prevent further potential abuse by 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)(2)-(4), F610, Investigate/Prevent/Correct Alleged Violation, 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 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: 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. A review of the facility policy titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan - Protection policy, undated, revealed, residents will be protected during an investigation whether it is abuse, neglect, exploitation, or mistreatment. The Administrator or the person in charge shall separate the alleged victim and the accused person immediately and maintain that separation until investigations are completed. While the investigation is being conducted, the employee accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. 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. 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 with staff regarding abuse policy and prevention initiated 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 would have known the detailed statements, CNA #1 would have been suspended the day the incident occurred. The Administrator stated her understanding was that LPN #2 called the DON to report CNA #1 told Resident #1, You are not going to put your mother [***] ing hands on me. The Administrator stated at the time the DON was notified, they needed more information about what happened and didn't know all the details. The Administrator stated CNA #1 worked at the facility on [DATE], 1[DATE]19 and 12/23/2019, until she was called to the office, on 12/23/2019, to make a statement regarding the incident. The Administrator stated CNA #1 got mad and left during the interview. The Administrator stated the facility's policy revealed it is their responsibility to protect residents immediately. The Administrator stated she believed at the time of the incident ([DATE]), they removed CNA #1 away from the resident, and placed her on another hall in the building, thus protecting Resident #1. During an interview, on 01/21/2020 at 12:38 PM, the Director of Nursing (DON) stated she received a call from Licensed Practical Nurse (LPN) #2, on [DATE], regarding an incident in the dining room between Resident #1 and CNA #1, where they had cursed at each other. The DON stated she told LPN #2 to instruct LPN #1 not to allow CNA #1 to have any further contact with Resident #1. The DON stated that was the last thing she heard about the issue until she returned to the facility on [DATE]. The DON revealed 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 back at the resident. The DON stated after she read the written statements, when she returned on 12/23/2019, she realized she should have sent CNA #1 home on [DATE]. During an interview, on 01/21/2020 at 4:37 PM, CNA #1 stated, on [DATE], she was assigned to two (2) rooms on the 100 Hall, which included Resident #1's room. CNA #1 stated she stayed on the 100 hall and took care of Resident #1's roommate (Resident #7). CNA #1 stated she saw Resident #1 about three (3) more times, after the incident in the dining room. CNA #1 stated if Resident #1 was in the room, when she went to do patient care with Resident #7, she would leave and come back. An observation of Resident #7, by the State Agency, revealed the resident was non-verbal. A review of the time sheet for CNA #1 revealed she worked at the facility on [DATE], 1[DATE]19 and 12/23/2019. A review of the facility's assignment sheet, dated [DATE], revealed CNA #1 was assigned to Resident #1's room and one other room on the 100 Hall. Review of the facility's Activities of Daily Living look back report for Resident #7 (roommate of Resident #1), dated [DATE], revealed CNA #1 provided care for Resident #7 at 10:44 AM, which was approximately two (2) hours after the incident with Resident #1 in the dining room. 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 |