cms_SD: 38
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 38 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 550 | J | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, policy review, and admission packet review, the provider failed to ensure one of one sampled resident's (49) personal space and privacy was protected from one of one sampled resident (17) who had a history of [REDACTED]. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 03/15/18 at 11:15 a.m. to the administrator and the director of nursing (DON), and by phone to the president of the Custer market for Regional Health. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from resident 17's verbal, physical, and sexually inappropriate behaviors. PLAN: The administrator and DON submitted a preliminary immediate plan of correction that required additional information. On 3/16/18 at 11:47 a.m. the administrator and DON provided the immediate P[NAME]. That P[NAME] was accepted at that time and included: *For resident and staff safety: -Resident was placed on one-to-one observation after the notification of Immediate Jeopardy related to abuse until transfer to Custer Regional Hospital for evaluation on 3/15/18 at 1645 (4:45 p.m.). Prior to transfer, the Director of Nursing at Custer Regional Senior Care began a petition for involuntary emergency commitment. After evaluation at the hospital, the resident's emergency involuntary commitment was upheld. The resident was then transferred by Custer County Sheriff's office on 3/15/18 at 1900 (7:00 p.m.) to the Human Service Center, Yankton, and SD for further evaluation and treatment.*For patient discharge and family notification: -Information about the discharge to the emergency department and the involuntary commitment was given to the family. The family verbalized support of the process and discharge to the Emergency Department for evaluation. The family also supported admission to the Human Services Center.*For policy and procedure review: -Review and revision of the following policies were completed and revisions were made as deemed necessary (Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting process), including feedback from the Medical Director. *For staff education: -Immediate education will be completed with all staff prior to their next shift, which will include the review of the following policies: Abuse and Neglect, Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident Abuse; Preventing Resident Abuse; Resident Rights; and Resident Incidence/Variance Reporting Process. We will focus on identifying signs and symptoms of abuse, how to report, when to report and who to report to in order to address the potential for a similar situation in the future. Staff will be knowledgeable about protecting themselves and other residents in accordance with our policies. Education completion will be reported to the Administrator. *For Medical Director education: -The review of the admission process and following policies will occur with the Medical Director upon his return the week of 3/19: Abuse and Neglect; Recognizing Signs and Symptoms of Abuse/Neglect; Resident to Resident abuse; Preventing Resident Abuse, Resident Rights; Resident Incidence/Variance Reporting process. On 03/27/18 at 11:45 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Review of resident 17's 3/8/18 required Healthcare Facility Event Reporting form revealed: *Date and time of event: 3/8/18 0800 (8:00 a.m.). *Type of event being reported: Suspicion/allegation of abuse/neglect. *Allegation type: Other: Resident to resident physical contact. *Suspicion/Allegation of Abuse/Neglect: -Resident to resident/Patient to patient. -Both names and cognition: Resident in the morning grabbed a female residents butt which cause (ed) her to fear him. *Provide a brief explanation of event being reported. Please include names (s) of Patient/Resident/Personnel/Family/Visitors involved with event: -Residents morning nurse walked into residents room to give morning meds and said good morning, resident than proceeded to grab the female nurse by the neck and tried to lick/kiss. His nurse backed away while removing his hands from her neck asking patient (resident) to please take respiratory meds. Resident than proceeded with his inhaler stating is not like your ta-tas there's milk than grabbed the nurses breast. His nurse explained this was very inappropriate and not acceptable to touch people, resident stated that's all you woman are good for and resident than tried to grab his nurse by the neck a second time, nurse proceeded to leave the room. Resident came out into hallway and smacked a staff members butt following a resident. The female resident he hit on her butt was very upset and fearful of resident. SS (social service) was asked to assist in alleviating his behavior, resident began to swing his cane at the female staff, the DON (director of nursing) was notified to assist in the situation in which resident after about 10 minutes was redirected into the office in which his primary physician was in the office, his physician attempted to redirect resident without success, resident was assisted to his room in which when male nurse attempted to give injection ordered, he became combative and injured a staff, resident attempted to get out of the facility when the DON was attempting to redirect, he did get the door open and staff successful after a few minutes in redirecting. Physician did assist with medication administration in a enclosed room after resident injured DON attempting to redirect him. Resident has had a history of [REDACTED]. MD (medical doctor) has adjusted his medication in an attempt to assist with decreasing his behaviors. His latest BIMS (Brief Interview for Mental Status) was completed in (MONTH) of (YEAR) and was documented as 12. Resident when discussing his behavior states 'I'm just crazy.' This afternoon resident is pleasant and ambulating around the facility no further behaviors noted this afternoon. *Investigation conclusion: -Conclusionary summary statement of facility investigation: It is questionable if having a roommate is escalating his behaviors as (resident 17's name) makes many comments about his roommate and status. DON and staff working on moving roommate to determine if this will assist in decreasing his agitation and outbursts with sexual behaviors. Every shift documentation monitoring an increase or decrease in behaviors to be completed due to increase in medication dose. *Substantiation and Action: -Was abuse/neglect allegation substantiated? Yes. -Why or Why not? Resident to resident sexual groping. *Was it a willful act? Yes. *Action taken by the facility: Personnel education and other were checked. *Other, please specify: Physician present at the time, new orders in medication, change in room mate. *No documentation to support: -Who the female resident was that he had physical contact with. -The cognition level of the female resident who was involved in that event. -Follow-up interviews with the staff members who had been involved or witnessed the event. -That an investigation and interview had been conducted with the resident or staff members who were touched by him in an inappropriate manner. 2. Interview on 3/13/18 at 2:26 p.m. with resident 49 revealed: *She had been: -The other resident mentioned in the 3/8/18 event with resident 17. -Coming out of the dining room after finishing her breakfast. -Watching for residents coming in and going out for safety purposes as it was crowded. -Coming out and resident 17 was going in to the dining room. *She stated: -He reached behind me and grabbed my left butt and squeezed a handful of it. -One of the male certified nursing assistants (CNA) (stated CNAs name) asked if I was alright. -I told him what happened and he said that wasn't right and would report it. -I went to my room for about thirty minutes to pull myself together and then went down to (name of SSD) office and she was aware of it. -I was told he was taken out of the dining room and that he had hit the table hard with his cane. *He had not attempted to approach her before that day. *She stated I heard he has had hands on with other residents. *In the past she had tried not to come in contact with him. *She stated: -I felt very violated that day when he grabbed my butt. -It was a violation of my privacy especially at this age. -I shouldn't have to fear for that type of behavior from an old man in a place like this. -It was an invasion of my rights. -I haven't seen him or heard him be inappropriate with the others but I do hear the staff tell him hey stop that. -I have heard he can be grabby and at this age would never think of stuff like this, thinking and worrying of old people doing stuff like that. *She: -Had not been injured when he grabbed her buttock. -Stated It was very unsettling and I was embarrassed. I could feel my face turning red. Review of resident 49's medical record revealed: *A BIMS score of fifteen meaning she was alert and oriented to time, person, and place. *On 3/13/18 at 9:59 a.m. the social service coordinator (SSC) S had documented: -Late entry for 3/8(18). -(Resident's name) approached SS and stated that another resident was walking out of dining room and grabbed her bottom. -She was distressed. -SS calmed her down and apologized that she had to endure that. -SS assured her that our DON would file a state report, and that we would assure that this resident did not do that to her again. *The documentation by the SSC S on 3/13/18 had: -Occurred five days after the 3/8/18 event. -Been the only documentation and interview by administration regarding the 3/8/18 event involving resident 17. 3. Observation and interview on 3/13/18 at 3:36 p.m. with resident 17 revealed he: *Had been sitting in his room watching television. *Was alert and pleasant to visit with. *Had remembered the event that occurred on 3/8/17. *Stated: -The other day the night nurse came in with meds, we got mad at each other and I'm not sure why. -She left and I went out to the dining room to eat. -The staff came and got me and gave me this shot, I thought I was dying but then I woke up. -The doctor was here and he helped them. -There was a lot of staff and they were grabbing me and my hands I have no idea why but there was a lot of them. -I get angry sometimes and not sure why. -I blackout and do things and can't remember them. *Several times he stated I have times where I black out and I can't remember the things I do. Review of resident 17's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had a BIMS score of twelve meaning he had moderate cognitive impairment. *He was: -Independent with all activities of daily living (ADL). -Able to walk independently with the use of a single-point cane. *He had: -The capability of wandering throughout the facility with a history of going into other residents' rooms. -A history of touching other female residents and staff members inappropriately and in an undignified manner. *The physician had assessed the resident every sixty days and as needed (prn) for any acute health care concerns identified by the staff. *The documentation from those physician's visits identified: -On 9/28/17: Follow up on chronic management of issues related to [MEDICAL CONDITION] associated with dementia and depression. He refers to himself as crazy. He says sometimes he voices or does crazy things. We have tried to taper quetiapine ([MEDICATION NAME]) and has had breakthrough symptoms that have really been distressing to other residents and staff and even to him. He is aware of the hallucinations and inappropriate behaviors. -On 11/9/17: In general terms we follow him for dementia and some associated behavioral issues with delusions and [MEDICAL CONDITION]. *He had been taking [MEDICATION NAME] 50 milligrams (mg) twice a day for [MEDICAL CONDITION] since 2/28/17. -A gradual dose reduction had been contraindicated d/t (due to) an increase in his behaviors would have occurred. *On 3/6/18 the physician had increased his bedtime dose of [MEDICATION NAME] to 75 mg d/t bizarre behaviors including some sexual references in front of the nurses. -Plan: We could make a small increase in quetiapine ([MEDICATION NAME]) dosage in the evening to try to help sleep better and see if this also helps him to control some of his impulsive behaviors sexual expressions. Review of resident 17's nursing progress notes from 5/4/17 through 3/14/18 revealed: *On 5/14/17 at 12:26 p.m.: Resident assigned seating in dining area moved to table with peer secondary to inappropriate touching of female peer. Staff will continue to monitor. *On 7/11/17 at 8:30 a.m.: The charge nurse documented: CNA reported that resident was in dining room after breakfast and touched her inappropriately on chest and twice on the hip; CNA reported this to me and will document in behavior log as well. *On 8/29/17 at 8:18 a.m.: CNA noted that resident was in the DR (dining room) attempting to kiss another female resident but she was vehemently stating 'no' to him. Intervened and stated to resident that that behavior is inappropriate and that female resident is stating no. This resident made a inappropriate facial gesture and said that 'I will get you next time.' I spoke to resident about the incident. Reinforced to him that he must not touch other residents. He states understanding at this time. *On 8/29/17 at 1:09 p.m. by the SSC S: It was reported to SS that (resident 17's name) kissed a female resident on the cheek and put his arm around another female resident who told him to stop; (he did comply). SS talked with (resident 17's name) explaining that he could not touch any resident without their permission. He stated he understood and would stop. -No documentation to support the physician and family had been notified. *On 9/7/17: -At 9:21 a.m.: The activity staff had requested the charge nurses assistance. The resident and another female peer were arguing over an exercise stick. The other resident had taken the exercise stick from him. The charge nurse assisted the resident to another area. The activity staff reported to the charge nurse This resident had also grabbed her (charge nurse) in an inappropriate body part as she was attempting to separate the residents. Staff was able to redirect him to sit in a different area, although resident did attempt to move back to female resident's chair, and then moved back to his chair. -At 9:55 a.m.: Staff reported that this resident again attempted to move back over to the female resident that he had altercation with. This resident then left the lobby and I spoke with him about the behaviors he was involved in. He indicated that 'it just starts.' I reinforced to him that he needs to not let it start. *On 9/11/17 at 4:06 p.m. by the dietary director: It has been brought to my attention that (resident's name) slapped one of my staff on her bottom. It happened on Wednesday the 6(th) of September. This morning at breakfast when taking his order he hand signaled groping her chest. *On 2/9/18 at 11:48 a.m. Resident tried to swat CNA on rear end, CNA dodged, and resident tried to strike CNA with fist. *On 3/8/18 refer to the above online reporting form. *No documentation to support: -Event reports or investigations had been completed on all of the resident-to-resident and resident-to-staff altercations above to rule out abuse/neglect. -The physician and family had been notified after each above event. -The inappropriate sexual behaviors exhibited above by the resident had been reviewed in full to ensure the mental health, personal privacy, residents rights, and dignity was maintained for all who had been involved in those altercations. Review of resident 17's current and revised care 1/15/18 plan revealed: *There was documentation to support his [DIAGNOSES REDACTED]. *The staff were to have redirected the resident when he: -Had inappropriate sexual behaviors or comments. -Attempted to touch other residents without their consent. -Wandered into other residents' rooms. *It confirmed he had episodes of inappropriate behaviors where he would say sexually inappropriate things and attempt to touch them. *The staff were to have monitored and recorded occurrences of behavioral symptoms and document per provider's policy. Interview on 3/13/18 at 9:38 a.m. with CNA F regarding resident 17 revealed: *She confirmed he had a history of [REDACTED]. *she stated: -He will attempt to do things to us CNAs that is embarrassing and inappropriate. -He slaps us on the butt. -He told me once I needed to take my pants down and do things for the other residents mostly his roommate. -The kiosk is by his room and sometimes when I am charting he will come out and grab at my chest or butt. *She had: -Requested not to work with him and would not walk into his room by herself. -Witnessed him attempting to kiss resident 36 on the forehead, hugging her, and sat by her today. *Resident 36: -Appeared to not have been bothered by his actions. -Had episodes of confusion. *The medication aide had reminded him his actions were inappropriate, and he moved to another spot. *She had been informed by administration they were reviewing his medications. Review of resident 36's medical record revealed she had a BIMS score of six. -That score indicated she had severe cognitive impairment. Interview on 3/14/18 at 9:16 a.m. with CNA O regarding resident 17 revealed he: *Was aware of the resident's inappropriate touching other female residents and staff. *Stated: -I'm male so he's not like that with me. -Last week he was very aggressive when he grabbed (resident 49's name) bottom. -She was very upset about it. *Had reported the incident to licensed practical nurse (LPN) [NAME] *Agreed it was: -A violation of her private and personal space. -Her right to be free from that type of behavior. Interview on 3/14/18 at 11:57 a.m. with LPN A regarding resident 17 revealed she: *Had been the nurse involved with the event that took place on 3/8/18. *She stated: -After that he tried to grab me a second time around the neck, and so I just left his room. -The bathaide came up and said he smacked her on the butt and (staff name) (CNA O) told me he grabbed another resident inappropriately by then he was in the dining room. -I went and got (staff name) (SSC S) and when we tried to approach him that his behaviors were inappropriate he got mad, started slamming his cane on the table, and screaming. -I went and got the DON to help and she wanted me to not be around him d/t being pregnant and his behaviors. -You just never know what to expect from him and it makes you uncomfortable and fearful. -He tends to single out females especially the bathaide and this one lady from another wing. I don't work down there so I'm not sure who she is but I can tell she is confused. She repeats the same questions a lot. -He's grabbed and touched me before and I don't like it, makes me uneasy. -We have been told to redirect him which we do. Sometimes it works and sometimes it doesn't. *Had not been exhibiting any behaviors after the shot he received on 3/8/18 of [MEDICATION NAME] until today. -She stated He's starting to approach female residents again. *Had confirmed: -His behaviors had been sporadic and with no consistent pattern. -The female residents and staff should not feel and fear from that type of violation. *Stated If I would have done that it would have been considered an assault. But since we are staff its not really looked at as a huge concern. Interview on 3/14/18 at 12:40 p.m. with CNA P regarding resident 17 revealed: *She: -Was the bathaide for the 100 and 300 wings. -Had been responsible for assisting him with his bath. *The resident was verbally, sexually, and physically inappropriate with her during those times. -At times he would have slapped her on the bottom. *She stated: -Recently he slapped me on the butt so hard that it hurt, and he just laughs about it. -He will tell you: --That is what womans are good for. --Womans are here to be sexual pleasing and we are not worth more than that. -It makes me feel very disrespected. -I know they have talked to him about his behaviors towards us and the residents, but I just don't think its been hard enough. -We are always told by the administration and (staff name) (SSC S) that they will take care of it. *She: -Was aware of the altercation he had with resident 49 and the staff on 3/8/18. -Stated (Resident 49) was very mad and upset. She stayed in her room the entire day. -Had reported all behavioral concerns involving the resident to her charge nurse. Interview on 3/14/18 at 8:30 a.m. with the medical director regarding resident 17 revealed he: *Was aware of the resident's inappropriate verbal, physical, sexual, and aggressive behaviors towards other residents and staff. *Was in the facility on 3/8/18 when the resident had exhibited uncontrollable and inappropriate behaviors. *Agreed the resident's type of behaviors that day would have been considered inappropriate and violent in nature. *Did not send the resident to the emergency room (ER) for treatment or evaluation since he was already in the facility during that time. *Assisted the staff with the administration of [MEDICATION NAME] by injection to the resident. *Was not aware of all types of behaviors the resident had exhibited. *Confirmed most of the resident's behaviors were sexual in nature. *Considered trying Depovera to try to control those behaviors but had not initiated it yet. *Confirmed: -The resident was taking [MEDICATION NAME] for his behaviors and had failed attempts of a gradual dose reduction (GDR) in the past. -The [MEDICATION NAME] was recently increased d/t inappropriate and sexual behaviors towards residents and staff. *Was not sure what triggered the resident's behaviors. *Stated: -His behaviors are just random. -I know his current roommate is failing which upsets him and has caused him to not sleep well. -He has a long history of [MEDICAL CONDITION], and we try to manage most behaviors with redirection and medications. -He clearly misbehaves and I can't say if this is appropriate placement for him or not. -We really don't have the resources and support for psych services in this area. -No we don't have psych support or resources to utilize. -He already has a long history of [MEDICAL CONDITION], so I really don't see the need for an inpatient evaluation. *Had been concerned about the other residents and staff safety but unsure what to do for it. *Agreed the resident would likely exhibit those types of behaviors again. Interview on 3/14/18 at 3:05 p.m. with the administrator, DON, Minimum Data Set (MDS) assessment coordinator, and social service coordinator (SSC) S regarding resident 17 revealed: *They confirmed: -He had [MEDICAL CONDITION] with a history of sporadic and verbal, physical, and sexually inappropriate behaviors. -His behaviors: --At times were a problem and had been discussed during stand-up meetings. --Were reviewed as needed (prn) by the interdisciplinary department team (IDT). --Had no specific pattern and recently had been more directed at females. --On 3/8/18 were the worse they had ever been. *Initially they thought his behaviors had been triggered from his roommate and related to baths. *The DON: -Stated He mostly has sexual comments. -Was not aware of any events involving other residents until recently. -Would have expected the staff to notify her when residents had uncontrollable behaviors. *The SSC S confirmed: -The resident had sexually inappropriate behaviors, and the most recent incident was the worst. -She had spoken with resident 49 immediately after the incident on 3/8/18 and again later that day. -She had not documented those discussions with resident 49 and should have. *They: -Had not been aware resident 49 stayed in her room that day. -Agreed since it was a traumatic event for resident 49, and there should have been follow-up with her. -Were unaware of any physical, verbal, and sexually and inappropriate behaviors towards staff prior to the incident with LPN [NAME] -Would not have allowed the staff to determine whether they wanted to work with a certain resident or not. -Would have tried to rearrange the staff assignments to accommodate those requests. -Had been aware he had stated he did not remember when those episodes occurred and what had happened. -Was unsure if he actually remembered them or not. -Confirmed all the staff were required to: --Complete the abuse mandatory training. --Report any events or behaviors where there was the potential for abuse to the supervisor or administrative staff. -Had a difficult time transferring residents with behaviors to other facilities. -Used to transfer residents with behaviors to the ER for evaluation and admission but now they could not. --There was no further comment as to why not. -Could have contacted the primary physician and had him sent to the ER if needed. *There was one psychiatrist the medical director used if needed, but those appointments would have been a couple of months out. *The medical director reviewed and ordered most of the medications for his residents who had behaviors. *They had: -Been working with the physicians to support referrals to a behavioral service located in the area for them to utilize. --That process had been taking a long time due to (d/t) the lack of understanding from the physicians and their support to utilize them as a resource. -Access to two psychologists for support and one would have been able to come directly to the facility. --Those services required a referral from the resident's primary physician. -Been aware of the need for those behavioral services in the facility. *There had been recent education provided for the staff on professionalism and how to handle resident 17 and his behaviors after the event on 3/8/18. -There was no documentation to support that education for the staff. -The DON stated: --The education was all verbal, and I talked only with the staff working that day. --They were told to tell the others. *The administrator: -Indicated they had not been aware of all the incidents that the surveyors mentioned and reviewed above. -Would have expected the staff and residents to have told them about those incidents. -Stated We would have responded to those incidents had we known it was occurring that frequently. *They had been concerned about the staff and resident interviews above and having no knowledge of all those issues and concerns. *No further comment was provided to support: -If resident 49 and other residents should have been interviewed after the incident on 3/8/18. -If those staff members involved in the 3/8/18 incident should have been interviewed as part of the investigation. Interview on 3/15/18 at 10:23 a.m. with the administrator regarding resident 17 revealed: *He stated: -I feel like (resident 17's name) is being villanized by (resident 49's name) and getting other residents to say he is out of control. -He did not know how they could have been at fault if they had not known all the concerns of those residents and were not aware of those certain instances. -I feel most things are staff driven with his behaviors and not directed towards other residents. *After further review of the resident's sexual behaviors involving cognitively impaired residents and their inability to give verbal consent he stated We should have involved behavioral services for (resident 17's name). Observation of resident 17 on 3/15/18 at 12:15 p.m. in the copy room revealed: *The surveyor had been waiting to use the printer. *The resident arrived in the room and stated They think I'm crazy and pointed to her chest. *The surveyor: -Looked down and the resident swiped his finger up towards her nose. -Thought he had been joking with her. *He had attempted to grab her copies and appeared to be agitated. *The surveyor: -Turned around towards the printer, and the resident grabbed her bottom. -Stated Oh we better not do that. *The resident: -Smirked at the surveyor. -Had been on one-to-one observation by the activity coordinator and LPN A at that time. -*They had asked him to go back with them after he grabbed the surveyor's bottom. -He walked quickly through the copy room, out the other side door, and away from them. *LPN A stated This is his normal behavior and he's riling up again. Review of the provider's 1992 Briggs Healthcare pamphlet in the admission folder regarding resident rights revealed: *As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights. *Exercise of rights: You have the right and freedom to exercise your rights as a resident of this facility and as a citizen or resident of the United States without fear of discrimination, restraint, interference, coercion, or reprisal. *Resident Behavior and Facility Practices: -Abuse You have the right to be free from verbal, sexual, physical or mental abuse. -Staff treatment: --The facility must implement procedures that protect you from abuse, neglect or mistreatment. --In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. --All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. *Quality of life The facility must care for you in a manner and environment that enhances or promotes your quality of life. Review of the provider's undated Welcome to Regional Senior Care pamphlet in the admission folder revealed: *Home: It is a home, a place where people live. Privacy is to be respected. Review of the provider's undated Resident Responsibilities paper in the admission folder revealed: *As a resident of the (facility name), you have many rights. Your help is appreciated in making sure the facility runs smoothly and meets your needs as well as those of your neighbors. The following are some guidelines for residents to follow to ensure a pleasant stay (facility name). -Be kind, considerate and respectful of your roommate, other residents, and staff. | 2020-09-01 |