| 48 |
SANDIA RIDGE CENTER |
325032 |
2216 LESTER DRIVE NE |
ALBUQUERQUE |
NM |
87112 |
2018-03-14 |
609 |
E |
0 |
1 |
YN7D11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure incidents of resident to resident abuse were reported to the State Survey Agency within 2 hours 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 fails to report allegations of abuse to the State Survey Agency, corrective measures may not be acted on, and the facility is unable to assure residents are free from abuse. The finding 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 (unidentifed resident), unknown what triggered resident to hit another resident (unidentifed). Resident (unidentifed resident) sustained a skin tear on in (sic) right bridge nose area. He 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 (unidentifed) 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 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 interview the Corporate Compliance Nurse (CCN), was asked about incidents of abuse with Dementia residents, she stated If they don't have a BIMs (Brief interview for mental status), they are not cognitive. If they are both not cognitive, the interpretation is, how do you state intent. The 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 they (incidents) needed to be reported. D. On 03/08/18 at 10:50 am, during 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 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. 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). |
2020-09-01 |