| 1 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2017-03-09 |
226 |
E |
0 |
1 |
KTFZ11 |
Based on observation, record review, and interview, the facility failed to protect residents during the investigation process for allegations of abuse for 6 (#s 8, 14, 26, 27, 28 and 32) of 36 sampled and supplemental residents. Findings include: Review of an incident report, dated 10/6/16, showed resident #8 sustained a 7 cms. reddish/brown bruise to her right wrist during an allegation of rough cares. The Plan to Prevent Further Abuse section did not show preventative steps taken by the facility to protect other residents from harm. The staff member identified in the allegation continued to work the floor with the residents through completion of her shift. Review of the facility's Abuse Policy and Procedure (prior to 3/9/17) did not show protective action was to be taken when a resident reported an allegation of abuse by a staff member. The policy and procedure failed to identify definitive steps for staff members involved in allegations of abuse. During an interview on 3/8/17 at 2:30 p.m., staff member S stated a procedure was followed when an allegation of abuse was voiced by a resident: -The social worker or nurse would be asked to talk to the resident. -Then the nurse manager would follow up and talk with the resident. -The nurse manager put in a 24-hour report to the state. -The nurse manager would interview all the staff members involved. -If needed, involved staff would be put on administrative leave. -The nurse manager would notify the Director of Nursing of the incident. -Education on abuse and resident rights would be repeated for all staff. Staff member S stated the CNA involved in resident #8's incident, self-reported to another staff member that the resident had complained of rough cares. During an observation on 3/9/17 at 8:06 a.m., staff member T brought an over-the-bed table into the dining room to be used by a resident, however the table did not fit under the resident's wheel chair. Staff member T pushed the table toward the dining room entrance. A female resident seated at a table close to the entrance stated, You can't leave that there (the over-the-bed table). There are two people with wheel chairs. Staff member T stated I know, and walked away. Staff member T's voice was rough, and her demeanor was abrupt. The female resident stated No you don't. Staff member T returned with a smaller table and stated See, I told you I knew, and I'm moving it now. Staff member T took the other table out of the dining room. Staff member T's demeanor was, abrupt and her voice sounded rough. During an interview on 3/9/17 at 9:30 a.m., staff member T stated Some residents say we are being rough with care, but it is because we are rushed. 2. Review of an incident report, dated 2/1/17, showed resident #14 was treated very very rough by staff member G, while assisting her with upper body dressing. Staff member C investigated the rough handling allegation between 2/1/17 and 2/6/17. On the reporting form, staff member C indicated staff member G was assigned to another cottage, during which time, interviews could be conducted with other residents. During an interview on 3/8/17 at 9:15 a.m., staff member C stated, usually alleged staff members were assigned to a different area until the investigation was final. However, about two weeks ago it was decided, during the managers huddle meetings, to put the alleged staff members on administrative leave with pay, until the investigations were finalized. This decision was made due to a recent increase in the number of allegations against the staff. Staff member C stated as a result of this investigation, two more residents came forward complaining about the same CNA rushing cares with them. She stated these allegations warranted further investigations about the CN[NAME] Staff member C provided the facility's abuse prevention protocol and stated the facility was in the process of updating the policy. 3. A record review of an incident report sent to the state agency, by the facility, dated 9/6/16, showed details of alleged staff rudeness and rough care during resident cares provided for resident #26 by staff member Y. The report showed that staff member Y was reassigned . pending further family interview and investigation of the complaint. A record review of an incident report sent to the state agency, by the facility, dated 1/17/17, showed details of alleged staff rudeness and rushed care, during personal cares for resident #28, by staff member T. The report showed that after the alleged abuse had been reported, staff member T was told by a nurse she needed to switch to another resident, and she was not supposed to work with the alleged abused resident. The report showed that staff member T said she did go into resident #28's room later that day because the call light was going and no one else was around. A record review of another incident report sent to the state agency, by the facility, dated 1/22/17, showed details for another report of rough cares by staff member T involving resident #32. The report showed that staff member T was placed on administrative leave until completion of this incident's investigation. A record review of an incident report sent to the state agency, by the facility, dated 2/9/17, showed details of alleged staff rudeness and disrespect during resident cares, provided to resident #27, by staff member Z. The accompanying investigation report, dated 2/14/17, showed that it was determined there was reason for concern with the care provided by staff member Z. The report said that staff member Z would be placed in discipline. The report showed, she will be moved to another Cottage until the current resident with concerns is discharged . The report did not indicate that staff member Z had discontinued providing resident cares after the allegation of abuse had been reported, or during the investigation of the allegation. During a meeting with the facility DON, and members of the abuse prevention committee, on 3/8/17 at 1:00 p.m., the committee members were asked what criteria was used to determine if a staff member, as an alleged abuser, was placed on administrative leave, or allowed to continue to perform cares for residents during the abuse incident investigation. Staff member B responded by saying that the committee members had recently concluded they needed to consider a change in the policy of how the facility conducted investigations of allegations of staff to resident abuse incidents. This was prompted by several allegations of staff to resident abuse events reported in the first two months of this year, and included one incident that was determined as substantiated following investigation. A new abuse education program had also recently been put together, and was to be conducted for all employees throughout all the LTC facilities within the next couple of weeks. It was discussed, during this meeting, that allowing an alleged abuser to continue to perform cares for any residents during abuse incident investigations had the potential of placing residents at risk for abuse. It was also discussed that the accused employee is due protection from those who might take the opportunity to allege further abuse. During an interview on 3/9/17 at 8:30 a.m., staff member A provided a copy of the facility's new abuse policy, and stated the changes in the policy had been signed into effect that morning, less than an hour earlier. A comparison review of the old and new facility abuse policies showed that changes had been made regarding removal from duty of staff members who were being investigated for an allegation of abuse. Under part II of Allegations of Abuse, Neglect, and/or Misappropriation of Funds, letter e of the old policy, was the statement The Resource Nurse, with support and guidance from the Unit Manager and/or their designee may remove from duty any employee being investigated for an allegation of abuse during the investigation process. The new policy states, The Resource Nurse . removes from duty any employee being investigated . The new policy goes on to show the employee suspected of abuse is to be placed on administrative leave pending completion of the investigation. If abuse is substantiated the administrative leave will be unpaid leave. It also stipulates that the employee's privacy is to be protected during the abuse investigation. It outlines the investigation process to be followed indicating who will review the alleged occurrence with the employee, who will inform the employee of the investigation results, and when the employee will be able to return to work. |
2020-09-01 |