cms_OR: 66
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 66 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 607 | F | 1 | 1 | NNTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to implement policies for the protection of residents to conduct thorough investigations and/or when to report allegations of abuse for 5 of 6 sampled residents (#s 7, 36, 42, 61 and 423) and failed to develop a policy for reporting incidents not involving abuse or serious harm or injury. This placed residents at risk for ongoing abuse. Findings include: 1. Resident 36 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The facility 6/2018 Abuse Policy and Procedures revealed: -Employees must report all allegations of abuse and an investigation would be completed and would include: interviews with staff and residents, staff who may have knowledge of the incident and an analysis of findings. The 10/19/18 MDS indicated Resident 36 was cognitively intact. On 12/14/18 at 1:00 PM Resident 36 indicated some staff treated her/him badly. Resident 36 further stated a night shift female CNA was verbally abusive and told Resident 36 she hated her/his guts. The CNA still worked at the facility and continued to assist Resident 36 with care. Resident 36 indicated she/he did not report the incident to facility staff and would not provide the CNA's name. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS) were notified Resident 36 reported a female night shift CNA was verbally abusive toward the resident. Staff 1 indicated she just finished a telephone conversation with Resident 36's family and was notified of the same allegation. On 12/17/18 at 12:04 PM with Staff 1, Staff 15 and Staff 16, Staff 1 stated she did not follow up on the information of allegation of verbal abuse toward Resident 36 per facility policy. b. The facility 6/2018 Abuse Policy and Procedures revealed: -Any incidents of sexual abuse were to be reported to the State agency immediately or within two hours. The Resident 36's current Personalized Bedside Care Plan indicated the resident was incontinent of bowel and bladder and two staff were required to assist the resident with bed mobility. One staff was to stand directly in front of the resident when the resident was assisted to roll in order to reassure the she/he would not roll out of bed. The 11/8/18 Investigation by Staff 1 (DNS) indicated Resident 36 reported Witness 2 (Former CNA) touched me. Whenever he is changing me, he feels me up. Resident 36 further reported the female CNAs giggled when Witness 2 touched her/him and did not intervene. The resident reported the incident occurred the other day. Resident 36 did not provide the female CNA's names. Staff who worked with Witness 2 were interviewed and Staff 1 ruled out abuse. The State Agency did not have a facility self report regarding the 11/2018 allegation Witness 2 inappropriately touched Resident 36 during incontinence care. On 12/14/18 at 3:05 PM with Staff 1 (DNS), Staff 15 (Administrator), Staff 16 (Assistant DNS), Staff 15 indicated if an allegation of abuse could not be ruled out the allegation was reported to the state. Staff 15 further stated the reporting timeframe depended on the amount of time it took to complete the allegation. Staff 15 indicated she was not aware the facility was responsible to report allegations of abuse immediately upon receipt of the allegation of abuse and also acknowledged Resident 36's allegation of abuse was not reported to the State Agency. 2. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility's 6/2018 policy on abuse prevention and reporting revealed employees must always report any suspected abuse to their supervisor, nursing administration or the administrator immediately. The investigation may include interviews of the resident and witnesses, an initial analysis of the information, what measures were taken to ensure resident safety and reporting to State Agencies. On 12/11/18 at 1:09 PM & 12/12/18 at 11:22 AM Staff 1 provided an investigation of the 11/6/18 incident between Resident 61 and Witness 7 (Former CNA). The investigation began with a staff report of the event on 11/7/18 at 2:50 pm (almost one day after the incident occurred). The facility's investigation lacked the following required information: * Staff failed to report verbal abuse of a resident by a staff in a timely manner. * The investigation lacked documentation of an interview of Resident 61 and other residents who may have had contact with Witness 7. * There was no information describing how Resident 61 was kept safe following the incident. * There was no indication State Agencies were notified within the 24 hour time frame. On 12/17/18 at 10:55 AM Staff 1, Staff 15 (Administrator) and Staff 16 acknowledged there was a failure to implement their abuse policy to ensure staff reported incidents timely, a thorough investigation was completed, the resident's safety was maintained and reporting requirements were met. 3. Resident 423 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Resident 42 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. The facility's 6/2018 policy on abuse prevention and reporting revealed investigations may include interviews of the resident and witnesses, an initial analysis of the information, what measures were taken to ensure resident safety and reporting to State Agencies. An Event Overview dated 8/7/18 revealed Resident 423 was exhibiting agitation and verbal behaviors. Resident 423 suddenly slapped Resident 42 on the upper abdomen causing Resident 42 to be startled and yell out. There were no interviews of either resident, staff who were present or other residents who may have interacted with Resident 423. There was no indication the incident was reported to the State Agency. On 12/13/18 at 3:26 PM Staff 1 (DNS) and Staff 15 (Administrator) acknowledged their abuse policy was not implemented appropriately to ensure a thorough investigation was completed or reported to the State Agency. 4. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The facility's 6/2018 Abuse Prevention policy includes the following: Employees must always report any suspected abuse to their supervisor, nursing administration or the administrator immediately. An investigation will be done on all allegations of abuse. Resident 7's 9/12/18 MDS revealed her/his BIMS (Brief Interview for Mental Status) score was 12/15 indicating moderate cognitive impairment. During an interview on 12/13/18 at 4:19 PM Staff 32 (CNA) stated Witness 7 (Former CNA) grabbed Resident 7 and caused bruises when she yanked her/him up in the wheelchair. Staff 32 further stated Witness 7 was rough with other residents in front of staff and visitors. Staff 32 indicated she informed Staff 16 (Assistant DNS) about her concerns with Witness 7. On 12/14/18 at 9:35 AM Resident 7 stated she/he had been treated roughly at times but denied feeling unsafe. On 12/17/18 at 10:55 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) stated they were not aware of Witness 7's rough treatment of [REDACTED]. 5. The facility's reporting requirements in the 6/2108 Abuse Prevention policy revealed any incidents of alleged abuse involving serious bodily injury or sexual abuse will be reported to local law enforcement and State Survey Agency immediately (or no later than two hours). The policy did not include guidance for reporting alleged violations that do not involve abuse or do not result in serious bodily injury and must be reported to the State Agency no later than 24 hours. During interviews on 12/12/18 at 8:50 AM and 10:43 AM and 12/13/18 at 2:00 PM Staff 1 (DNS), Staff 15 (Administrator) and Staff 16 (Assistant DNS) acknowledged the Abuse Prevention policy did not include reporting requirements for allegations that did not result in serious bodily injury or did not involve abuse. | 2020-09-01 |