cms_SD: 39
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 39 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 600 | J | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and policy review, the provider failed to ensure all residents and staff were free from the verbal, physical, and sexually abusive behaviors from one of one sampled resident (17). 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 12/6/17 Required Healthcare Facility Event Reporting form revealed: *The report and investigation had been completed by the director of nursing (DON). *Type of event being reported: Suspicion/allegation of abuse/neglect. *Allegation type: Other: Resident slapped another resident. *Suspicion/Allegation of Abuse/Neglect: -Resident to resident/Patient to patient. -Both Names and Cognition: Resident 17 and 26 had been typed in that area. No documentation to support their level of cognition. *Is the individual capable of providing an explanation of the event or capable of participating in investigation? The word no had been typed in that area. *Provide a brief explanation of event being reported. Please include names (s) of Patient/Resident/Personnel/Family/Visitors involved with event: -At approximately 8 am (a.m.) this morning, this resident (17) was walking out of the dining room, as CNA (certified nursing assistant) F was assisting resident (26) in a w/c (wheelchair) in to the dining room. As this resident passed the resident in the w/c, reached out and slapped him on the right forehead. When the CNA told him he cannot hit other residents, he then reached out and slapped the CNA in the right arm. He then put his fists up as if it (to) punch her, but CNA stated he was smiling the whole time and then he walked away. There were no red marks or any other apparent injury to the resident (26). *Law Enforcement and the social services department had not been notified, because there was no injury. *Investigation conclusion: -Throughout the investigation process and interview process, (resident 17's name) stated he did not do this as an aggressive act, he demonstrated to this writer that he tapped the other resident on the forehead in a manner and stated good morning, (resident 17's name) did tap this writer on the forehead very softly on three occasions and his comment each time was that he was getting his attention with stating good morning. (Resident 17's name) latest BIMS (Brief Interview for Mental Status) is noted as 12 completed in October. In review of documentation, no other physical behaviors have been noted in regards to other residents. Staff to monitor for any agitation or further incidences. Other resident involved unable to give his version of what occurred. This writer explained how his actions could have been perceived by others. *Was abuse/neglect allegation substantiated: -No. -Why or why not? Resident did not do out of aggression. *No documentation to support: -There had been the potential for abuse as demonstrated by the resident's behavior towards another resident. -An incident report, investigation, and interview had been completed on the resident he had touched in an inappropriate manner. Review of resident 26's medical record revealed: *A BIMS score of 9. *That score indicated he had: -Mild cognitive impairment. *The potential to have been interviewed on the above incident with resident 17. Review of resident 17's 3/6/18 Behavior Incident Report form revealed: *At 12:23 p.m. licensed practical nurse (LPN) A had approached the resident and asked him to provide a urine sample. *Incident Description: Resident was asked to give a urine sample. Resident then responded with you hold the cup and I'll pull my big peter out. Resident was educated that this kinda (kind of) talk was not appropriate. He than responded with you ask my bathaide how big he is she was rubbing and pulling, do you want to see? Resident reminded again not appropriate to talk to other(s) this way and told to let a nurse know when he needs to urinate. Resident responded with fine I'll say it in (another language) maybe you will understand. *Mental status: Oriented to person, situation, place, and time. *The DON had reviewed the incident with no further action taken. Review of resident 17's 3/8/18 Required Healthcare Facility Event Reporting form revealed: *The report and investigation had been completed by the DON. *Date and time of event: 3/8/18 at 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 18 and 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. Surveyor 2. Interview on 3/13/18 at 9:45 a.m. immediately following the resident council meeting with resident 49 revealed she: *Waited until all residents at the group meeting had gone. *Stated: -There is a guy here that grabbed me on the bottom the other day. -She had reported the incident to social services. -He makes me feel nervous. He goes all over the place and you never know what he is up to. -I try to avoid walking by him in the dining room or hall. -I don't know how long he is going to be here. -The staff talked to her about the incident and said they were going to report it to the state. -I don't know how many times he gets. It might be three strikes and you are out. -She felt very uncomfortable when he was around. Especially after he had grabbed her bottom in the dining room. *Agreed to have another surveyor visit with her about the above incident. Surveyor: 3. 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 social service coordinator) (SSC S) 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. 4. Interview on 3/13/18 at 5:56 p.m. with an anonymous resident revealed he/she: *Had concerns regarding a male resident who walked around with a cane. *Stated: -He is mean to another resident and it's mostly when staff are not around. -He will hit her in the legs with his cane. -She is confused and doesn't say anything. -A few days ago I was in the lobby and he wanted her to do something or go somewhere and she wouldn't go. He then swatted her in the legs with his cane. -Now none of the other women will sit by him they are probably afraid of him. -I know I would be but he leaves me alone. *Had not reported that incident and others that had been witnessed to the staff. *Agreed those incidents should have been reported. *Stated Nothing will change if I do. Medical record review of the above resident revealed a BIMS score of fifteen. -That score supported there was no problem with memory recall. 5. Random observations starting on 3/12/18 at 11:45 a.m. through 3/15/18 at 9:30 a.m. of resident 17 revealed he had: *Been independent with ambulation. *Been able to ambulate throughout the building without difficulty. *Not required supervision or oversight by the staff while ambulating. *Required the use of an assistive device while walking. -That device had been a wooden, single-point cane. *Spent most of his time in the lobby area participating with activities. 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: --Verbal, physical, and sexually inappropriate behaviors towards residents and staff. --Taking scissors, finger nail clippers, and knives from the activities and dietary department. *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. *The pharmacist had completed monthly chart reviews on the resident with recommendations made. -The physician had declined to attempt any further GDR on his [MEDICATION NAME] d/t a result of his behaviors worsening. 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. -There was no documentation to support: --What type of inappropriate touching had occurred. --An incident report and investigation had been completed on both residents to rule out abuse. --The female peer had been cognitively aware enough to give consent for that type of touching. --There had been no mental distress for the female peer after being touched inappropriately. *On 7/11/17 at 8:30 a.m.: the charge nurse had 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 7/20/17 at 10:55 a.m.: A quarterly assessment completed by the SSC S. She had documented he had minimal depression with a BIMS score of fifteen. That BIMS score was an improvement and indicated his memory recall was intact. He had no behaviors or [MEDICAL CONDITION] during her assessment period. -Her assessment period for review was 7/11/17 through 7/17/17. Those dates would have included the above incident on 7/11/17 involving inappropriate touching of a staff member. *On 7/24/17 at 8:20 a.m.: Hsk (housekeeping) staff states resident hit her on her side and she told him to stop and that it is not ok to do that and that he shouldn't touch her. He then put up a fist and said I'll hit you. I spoke with him and said that it is inappropriate to hit anyone and that he must not do that again. He stated understanding. *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 SSD, 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: --An incident report and investigation had been completed on both residents to rule out sexual abuse. --There was no assessment for mental distress on the female peer after being touched inappropriately and kissed without her permission. *On 9/7/17: -At 9:21 a.m.: Activities staff person motioned me to the lobby as two residents (this male resident and a female resident) were having an altercation. Female resident had grabbed his stick that was used for exercise class and this resident responded by getting close to her and make gestures to her with his hand. I came and assisted the resident to have a seat in a different area, which he reluctantly did. The activities staff told me this resident had also grabbed her in an inappropriate body part a 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. -An incident report and investigation had not been completed on both of the residents. -There had been an incident report completed on the female resident. *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 9/29/17: He had several events of inappropriate behaviors with residents and staff. -At 11:03 a.m. the SSC S documented: SS heard yelling in the lobby this am. SS observed (resident 17's name) and female resident standing facing each other. A CNA who is a Spanish speaker began to assess the situation with (resident 17's name). (Resident name) stated that this 'crazy lady' stood up and begain (began) yelling at him. He states he did not make jabbing motions with his cane at her, and that he did not touch her or attempt to. He started yelling when she did because he wanted someone to help him in the situation. -At 1:36 p.m.: Bath aide asked me to come into the tub room. She states this resident has been talking mean to her and calling her a liar. I spoke with this resident and asked him not to speak inappropriately or mean to anyone. He did not respond as to whether he would cooperate or not. Bath aide will report any further behavior issues. -At 3:45 p.m. the SSC S documented: CNA and her supervisor approached SS this afternoon report (resident' name) had been verbally aggressive and demeaning to CN[NAME] She was in tub room with (resident's name) giving him a bath and he appeared upset; he began saying inappropriate comments, and humiliating racial comments to aide. He then began to state that the aide was pretty when she was mad. She asked him to stop and stated she would get a nurse. He stated he didn't care because all of you are a bunch of witches. He continued to make personal, racial statements to CN[NAME] This writer advised that she not continue working on his hall as this was a very upsetting incident for her. SS reported to DON. Nursing will f/u (follow-up) with this situation monitoring (resident's name) behavior. -No documentation to support: --When the nursing department had investigated the above situations from 9/29/17. --What further action the nursing department had put in place after their investigation and review of the above incidents involving the resident. *On 10/8/17 at 8:00 a.m.: Resident became physically combative when he grabbed public restroom key and was told by CNA he was only to use restroom in own room; struck at CNA with clenched fist, hollering that he wanted to use public bathroom. Kicked at door of bathroom when key was taken. Reminded that bathroom in his own room was only part way down hall. Behavior remained verbally hostile for several moments. *On 10/16/17 at 1:09 p.m.: A quarterly assessment had been completed by the Minimum Data Set (MDS) assessment coordinator. She had documented He is currently receiving antipsychotic and antidepressant medication daily. In review of documentation, his provider documentation of 9/28/17 notes that his recommendation to remain at the current dose of [MEDICATION NAME] at 50 mg is effective and this was increased in February, resident does not want this dose changed as per provider documentation on the above date. Assessment completed and care plan updated. Continue to monitor for needs and changes in status. *On 10/17/17 at 1:21 p.m.: A quarterly assessment had been completed by the SSC S. She had documented a decline in his BIMS score from 15 to 12. That score indicated his memory recall was moderately impaired. *On 12/1/17 at 11:38 a.m.: Bath aide reports that this resident made multiple sexually inappropriate comments to her as she was assisting him with bathing in tub. I spoke to him, asking him to please not use that type of language with staff or anyone. He states he can't help what he says and that it just happens. *On 12/3/17 at 10:30 a.m.: CNA reported that this resident spoke inappropriately to her this a.m. I asked him to please not speak to any staff in this way. He states he can not help it when he does it, it just happens. *On 12/6/17 at 10:28 a.m. refer to the above online reporting form. *On 12/7/17 at 8:00 a.m.: As aide was walking into the resident's room to answer other resident's light, this resident put his hand on the aide's lower back and pushed aide saying they were in his way. Aide asked this resident to please not touch me. Then this resident put his fists up as if he was ready to fight. Aide asked this resident to please go ahead and enter the restroom where he was and leave the room and told aide to take her pants off and get into the roommates bed and give him some (foul language). Aide and roommate asked this resident many times to please stop and enter the restroom, when finally he did. -No documentation to support: --An incident report and investigation had been completed to ensure no type of abuse had occurred. --Further action had been completed by the SSC S, administration, and IDT to ensure the roommate's mental status had not been effected by the resident's verbal and physical behaviors towards himself and the staff. *On 1/8/18 at 1:09 p.m.: A quarterly narrative had been completed by the SSC S. -No documentation to support: -The inappropriate behaviors the resident had exhibited above since his last assessment. -What action had been taken to ensure the mental and physical safety well being had occurred for all residents and staff involved. *On 1/10/18 at 12:37 p.m.: A quarterly narrative had been completed by the MDS assessment coordinator. Usually calm and cooperative, but he does have episodes of inappropriate behaviors and sexually explicit comments towards staff. Usually is redirectable. (Physician's name) documented in (MONTH) that a decrease in the resident's [MEDICATION NAME] and [MEDICATION NAME] causes decompensation of his behaviors. Last period of episode was 12/7/17. *On 1/19/18 at 10:48 a.m.: Bath aide reported that patient said, That she better have her papers and that she was illegal immigrant. DON was notified of the comments by bath aide. DON lets the resident know that his comment was not appropriate and that is not ok to talk to staff in that way. Nurse called daughter, no answer at this time, left VM (voicemail) to call the nurse back at the facility. The call was to inform family of the patient behaviors. *On 1/22/18 the staff had reported the resident going into other resident's rooms to use their bathroom. *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 3/6/18 refer to the above incident reporting form. *On 3/8/18 refer to the above online reporting form. *On 3/14/18: -At 5:08 p.m.: Resident told female peer, when she stood up from dinner table to go on and get out of here. Female peer responded, 'shut up and leave me alone.' This resident then said, 'I said go on and get the (foul language) out of here.' This resident will be moved to another dining table away from female peer effective next meal. Staff will continue to monitor. -At 6:39 p.m. the SSC S documented: It was reported to SS that (resident 17's name) had made inappropriate comment to female resident in dining room. SS went to his room much later to interview him; asking if anything happened in the dining room tonight and he related the following: Nothing happened in the dining room tonight. Sometimes I say things that get me into trouble. I get moved all the time in the dining room. I was sitting with a lady that is skin and bones and she won't eat, just falls asleep. I saw an empty table so moved my stuff to the table in the back of the room. I like to eat by myself. A lady at the next table got up and was mad and stared at me and left; The other ladies were talking bad about me too. I don't remember what I said or what she said. SS informed (resident's name) that he would not be sitting close to those ladies anymore as it wasn't working out for anyone. He said he was sorry. SS talked with nurse to make sure family was notified of alleged incident. *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. -The physician and family had been notified after each above event. -What interventions had been put in place to ensure that type of behavior exhibited by the resident would not have occurred again. -The inappropriate verbal, physical, and sexual behaviors exhibited above by the resident had been reviewed in fu | 2020-09-01 |