| 47 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2018-03-14 |
607 |
E |
0 |
1 |
YN7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their policy regarding reporting incidents of resident to resident abuse and failed to ensure the results of an investigation was reported to the State Survey Agency within 5 days for 7 (R #s 33, 62, 71, 87, 93, 97 and 108) of 7 (R #s 33, 62, 71, 87, 93, 97 and 108) residents reviewed for abuse. If the facility is not reporting and investigating resident to resident abuse according to policies, then the facility is likely to be unable to determine the cause and identify strategies for preventing further abuse. The findings are: [NAME] Record review of the Resident Management System (RMS) Summary Reports revealed the following resident to resident altercations with alleged abuse: 1. On 04/06/17, This resident (R #97) had a physical altercation with another resident, (who was not identifed in report), unknown what triggered resident to hit another resident. He sustained a skin tear on in (sic) right bridge nose area. The unidentified resident would not allow nurse to administer first (aid), he was combative and attempted to hit nurse. 2. On 05/11/17, During breakfast this resident (R #97) became annoyed with female resident (who was not identifed in report), Please identify who attempted taking (sic) his drinks, was persistently bothering him with conversation and calling him daddy .female resident was directed to another table but came back to stand next to him. (R #97) then got up and slapped female resident several times in face. 3. On 07/22/17, This resident (R #97) was walking into dining room when (R #71) stood up and told him not to sit in the chair. This resident then pushed (R #71) with both hands into the wall. Nurse and CNA (certified nursing assistant) unable to intervene before contact was made between residents. 4. On 09/30/17, This resident (R #97) struck/pushed another resident (R #87) to the floor, and attempted to continue attack on his victim was (sic) lying on the floor. 5. On 10/28/17, Resident (R #33) stood up from his wheelchair and grabbed onto the back of this residents (R #97) chair he was sitting in. This resident then stood up and pushed (R #33) causing him to fall on the floor. This resident then reached down grabbing (R #33's) shirt trying to pull him up off floor. 6. On 01/12/18, Resident hit (R #108) while he was eating his dinner. (R #108) then hit him back with his cane causing a laceration on this resident's (R #97) forehead. 7. On 01/14/18, Resident (R #97) was sitting at dining room table with a male resident (who was not identifed in report), (un readable) heard calling out. Upon entering room, both residents (R #97 and the unidentified male resident), (unreadable), was pulling on a female resident's (not identifed in report) hand. Resident's (R #97 and unidentifed male resident) hands were separated and (unidentifed) female resident was asked if she would like to move to another seat. Resident (Unidentifed female resident) replied yes and was assisted to another table in a different section of the dining room. Each resident (all three) was examined for injury. Upon visual inspection of hands, a skin tear upon the back of (unidentifed) male resident's hand was located between thumb and index finger. 8. On 01/22/18, Resident (R #97) was found by CNA in a neighboring room. Resident was witnessed pulling on the arm of another male resident (R #93) who was on the floor. 9. On 01/31/18, Resident (R #62) was found on the floor on his back in room [ROOM NUMBER] (R #97's room). (R #97) had his hand on resident's wrist. B. On 03/08/18 at 9:36 am, during an interview with the Director of Nursing (DON) regarding R #97's incidents of resident to resident abuse, she stated that she would not report as abuse, due to No intent and no major injuries. C. On 03/08/18 at 9:48 am, during an interview the Corporate Compliance Nurse (CCN), verified that the incidents involving R #97 and resident to resident abuse, were not reported to the State Agency because they felt that it was a behavior and not intended to injure other residents. She stated that most of the cases were provoked incidents and they didn't feel he was intending to hurt somebody. The CCN stated that they (staff) didn't feel like the incidents needed to be reported. D. On 03/08/18 at 10:50 am, during an interview the DON confirmed that all nine incidents mentioned in Finding 'A' (Incidents dated 04/06/17, 05/11/17, 07/22/17, 09/30/17, 10/28/17, 01/12/18, 01/14/18, 01/22/18 and 01/31/18) were not reported to the State Agency. E. On 03/08/18 at 11:49 am, during an interview the Administrator stated that resident to resident abuse, Would be somebody attempting to hurt somebody. When asked about Dementia (decline in mental ability severe enough to interfere with daily life) residents, she stated that residents Are not willfully doing it. They are not going after somebody. The Administrator verified that the incidents were not reported to the State Agency, stating We didn't feel like the intent was there. It was a response to the situation. F. On 03/08/18 at 11:05 am, the Administrator was asked to provide the internal investigations for the suspected incidents of resident to resident abuse for: 02/13/18, 02/09/18, 09/30/18, 01/12/18, 10/28/17, 01/14/18, 01/22/18, and 01/31/18. [NAME] On 03/08/18 at 11:49 am, during an interview the Administrator provided 3 documents for the internal investigations: 1. RN (registered nurse) #3 stated, In reference to incident on unit 100 from a few days ago, Sep 30, (YEAR), after reflection, I have come to the conclusion that the resident in question was responding behaviorally, and was not acting with malice toward the other resident. 2. Handwritten statement (not dated) states, To whom it may concern, this nurse went into room [ROOM NUMBER] and found (Name of R #62) on the floor. (Name of R #97) had his hand on his wrist. (Name of R #97) was not agitated or angry. He was easily redirected. Both residents were separated and redirected. 3. A skin integrity report for R #79 (not dated), stated No skin impairment. The Administrator did not provide any other documentation showing that investigations were completed on any of the incidents in question. The Administrator verified that she does not document interviews or the findings of investigations. H. Record review of the two reported incidents on 02/09/18 and 02/13/18, revealed no documentation showing that interviews were conducted with staff to determine what happened before the incident, resident behaviors before, during and after the incident, residents expressions or signs of aggression or fear or if there were witnesses. I. Record review of the Abuse Prohibition Policy dated 09/01/16, revealed The person witnessing or suspecting the alleged abuse (reporter) will- with assistance from his/her supervisor, CED (Center Executive Director), or designee - report within 24 hours the allegation of abuse, neglect, or misappropriation of property to the (Name of State Licensing Authority). The CED or designee will report findings of all completed investigations to officials within five working days of the incident or in accordance with state law, and take all necessary, corrective actions depending on the results of the investigation. |
2020-09-01 |