| 97 |
WEST SHORE HEALTH CENTER |
415028 |
109 WEST SHORE ROAD |
WARWICK |
RI |
2889 |
2017-10-25 |
226 |
D |
1 |
0 |
REJ311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined that the facility failed to ensure that the Abuse Prohibition Policy and Procedure was implemented related to investigation and reporting to the state agency for an injury of unknown origin and potential abuse in 2 of 8 facility incidents reviewed affecting sample residents (ID#1 and 10). Findings are as follows: The facility's policy titled, Abuse Prohibition, revised 3/31/2017, states, in part, Abuse .Sexual-includes sexual harassment, coercion or assault . .Injuries of unknown origin-an injury that satisfies both of the following conditions: The source or cause of the injury was not observed by any person or the source of the injury can not be explained by the resident AND the injury is suspicious because of the extent of the injury OR the location of the injury OR the number of injuries observed at one particular point of time OR the incidence of injuries over time . Investigation- It is the DNS/designee's responsibility to act immediately to: .Obtain statements from witnesses . It is also the responsibility of the Director of Nursing to ensure that: .personnel and witness statements are obtained timely .the investigation is comprehensive and timely documented appropriately. It is the responsibility of the Nursing Home Administrator to: Notify the appropriate agencies in writing. Submit the report of the allegations and the results of the internal investigation to the Department of Health within 5 working days of the original filing . 1. Review of a community reported complaint received by the State Agency on 10/23/2017 revealed on or about 10/11/2017 staff discovered bruising on Resident ID #1's pubic bone which the facility told the complainant was caused by a diaper. The complainant revealed that s/he requested an investigation by the facility and took photographs of the injury. Record review for Resident ID#1 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A 10/10/2017 11:52 PM progress note states, in part, During HS (hour of sleep) care CNA (certified nursing assistant) reports ecchymotic (bruise) that was not there when she worked last night. assessed with [REDACTED]. Ecchymotic area noted to from pubis mons to right hip Reported to DNS via telephone. Will continue to monitor . A 10/11/2017 12:52 PM progress note written by the Assistant Director of Nursing Service (ADNS) states, in part, resident noted with an ecchymotic from her pubis mons to (his/her) right hip, area is linear in appearance and is where (his/her) brief is placed, current brief is a large and an extra-large brief will be used, area measures 6.2 x 16 centimeters (cm) . Review of the facility's investigation revealed a handwritten note written by the DNS dated 10/11/2017 which states, ADNS wound nurse assessed ecchymotic area. Questioning brief sized bunched and too small, resident also on ASA (aspirin). Brief size changed. Family notified. Further review of the facility's investigation revealed two handwritten notes written by the Administrator. The first note, dated 10/11/2017, states, in part, This writer was called to the resident's room .family was present and wanted me to view the resident bruise on pubic area. We discussed how it was small yesterday and has spread across brief line. I assured them I would do an investigation. The Administrator's second note, dated 10/13/2017, states, in part, Talked to (family) of (resident) (s/he) was content with the findings of my investigation . However, the family subsequently filed a complaint with the State Agency requesting an investigation into the injury on 10/23/2017. Further review of the investigation file and resident's record failed to reveal additional personnel or witness statements, that a comprehensive investigation was documented, or reporting to the state agency. In an interview with the Administrator on 10/25/2017 at approximately 10:00 AM she revealed that after speaking with the initial assessing nurse and the ADNS (who investigated the ecchymotic area) the investigation stopped as the injury did not appear suspicious. Additionally, she revealed that no other statements were collected, possible maltreatment was never investigated, and that the state agency was not notified of the injury because the facility was confident in determining the cause of the injury. 2. Upon investigating a facility reported complaint involving Resident ID#2 an additional allegation of resident to resident abuse, related to touching another resident in a sexual/inappropriate manner on 4/26/2017, was discovered by the surveyor. Record review for Resident ID#2 revealed an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. A progress note dated 4/26/2017 at 10:40 AM states, in part, .CNA reported to writer that resident was observed in another . resident's (Resident ID#10) room touching (him/her) in a sexual/inappropriate manner . Review of the Nurse Practitioners's note dated 4/27/2017 at 11:30 AM, states, in part, .Nursing verbalized concern last evening r/t (related to) patient engaging in sexually inappropriate behavior with a resident. (S/he) was put on 15 minute checks r/t this event, though later on that evening was then accused by another . resident of inappropriate/abusive behaviors . In an interview with the with the Administrator and the DNS on 10/25/2017 at 1:40 PM they revealed that an investigation was not completed because Resident ID#2 is cognitively impaired and unable to form intent to abuse. Additionally, they revealed that the CNA that observed the incident no longer works in the facility, that her statement was not collected, and that the incident was not reported to the state agency. During a subsequent interview with Supervisor Staff Nurse A on 10/25/2017 at 2:30 PM she revealed that was told by the CNA of the incident in the morning of 4/26/2017 but was unsure of exactly what occurred. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions. |
2020-09-01 |