cms_OR: 67
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 67 | PROVIDENCE BENEDICTINE NURSING CENTER | 385018 | 540 SOUTH MAIN STREET | MOUNT ANGEL | OR | 97362 | 2018-12-19 | 609 | 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 ensure allegations of abuse or neglect were reported appropriately for 5 of 6 sampled residents (#s 7, 36, 42, 61 and 423) reviewed for abuse. This placed residents at increased risk for ongoing abuse. Findings include: The facility's policy on Abuse Reporting (undated) indicated anyone who suspects abuse should immediately notify his or her immediate supervisor, the Director of Nursing or the Administrator. After receipt of a report of potential abuse an investigation should be started immediately. Once the initial investigation is completed, it will be given to the resident care manager for a final investigation, then to nursing administration or the administrator for continued investigation or follow-up. Nursing administration/Administrator will report to Adult Protective Services as appropriate. Any incidents of alleged abuse involving serious bodily injury or sexual abuse will be reported to local law enforcement and survey agency immediately (or within 2 hours). The Administrator and DNS should be notified immediately whenever local law enforcement is notified of an incident occurring at the facility. 1. Resident 61 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. According to complaint intake information, an 11/6/18 incident of verbal abuse by a CNA toward a resident was reported to the Oregon State Board of Nursing (OSBN) on 11/16/18 (ten days after the incident). OSBN subsequently forwarded the concern to Adult Protective Services (APS) and they notified the nursing facility survey unit. On 12/11/18 at 11:31 AM Staff 1 (DNS) and Staff 16 (Assistant DNS) indicated Resident 61 was involved in an incident of verbal abuse from Witness 7 (Former CNA) on 11/6/18. On 12/12/18 at 11:22 AM Staff 1 provided an investigation regarding the 11/6/18 incident. The documentation began on 11/7/18 and concluded on 11/15/18. The investigation did not include information related to reporting to State Agencies. During interviews on 12/12/18 at 3:33 PM, 12/13/18 at 4:19 PM and 12/16/18 at 5:17 PM Staff 31 (CNA), Staff 32 (CNA) and Staff 33 (CNA) confirmed they witnessed or heard the verbal abuse and did not report the incident immediately after it occurred. All three staff notified Staff 16 (Assistant DNS) on 11/7/18, the following day. On 12/13/18 at 8:53 AM Staff 1 stated since they were unable to rule out abuse they called the OSBN to report the incident. Staff 1 stated she could not say why other State Agencies were not notified and agreed it should have been reported. 2. 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]. 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. The Event Overview did not indicate whether the resident-to-resident incident was reported to State Agencies. On 12/13/18 at 3:26 PM Staff 1 (DNS) and Staff 15 confirmed the incident was not reported to the State Agencies. 3. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. 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 any issues related to Resident 7 and staff did not report any problems. 4. Resident 36 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident'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 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. As of 12/14/18 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. | 2020-09-01 |