cms_UT: 35
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 35 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-09-05 | 609 | E | 1 | 0 | UVZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials in accordance with state law through established procedures. Specifically, there were resident to resident altercations that were not reported to the State Agency. Resident identifiers: 4, 5, and 8. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8's medical record was reviewed on 9/5/18. Resident 8's progress notes were reviewed and revealed the following entries: a. On 5/24/18 at 7:20 PM, Pt (patient) was being yelled at by a resident that he stole her money. Resident had a hold of pts sweat pants at the waist and would not let go. Nurse and aid (sic) saw what was happening and helped the 2 get separated. The resident then kicked the pt and the pt then punched the resident in the shoulder. Staff asked the pt to move away from the situation. Pt moved away from situation. No further incidents. b. On 6/20/18 at 5:20 PM, The CNA (Certified Nursing Assistant) walked into the resident room to let him know it was time to head down for dinner when she found him and another resident kissing and the other resident's sweatshirt was off and starting to take off the undergarments but was stopped by CN[NAME] Both of the residents were spoken to and told they were not to be going into the room together. Residents were removed from the room and sent to the dining room and put on 15 min (minute) checks. Family, MD (Medical Doctor), and DON (Director Nursing) notified. c. On 7/1/18 at 8:30 PM, Resident was found by nursing staff, in his room, in bed with a female peer, undressed from the waist down. Residents were separated by nursing staff, with female being assisted out of the bed and guided to her room by nursing staff. Resident redirected and reminded by nursing staff that he needed to stay out in public areas with female peers. Nursing staff will continue to monitor resident behaviors. Notifications: Resident's son (name removed), DON, MD (name removed.). d. On 7/9/18 at 10:00 PM, Aides were helping another male resident (2) with changing clothes in the resident's (2) room, when this resident (1) came into the room and hit resident (2) on right forehead. Resident (1) stated that he didn't know why he did .he knew it was wrong .but he thought resident (2) was being mean to aides at the time. Resident's were separated by nursing staff, Resident (1) was redirected from the room and reminded that he should not hit people, including other resident's or staff. Notifications: DON, NP (name removed), Residents son. e. On 7/19/18 at 10:31 AM, This report is for resident C. Resident B ambulated into resident A's room, this upset resident A and Resident A tried to push resident B out of the room which evidently pushed resident B to the floor. Resident C stepped into room from hall to get between these resident A and B and resident C punched this resident A in the face. When nurse entered room resident A was standing with aide assisting to calm him, resident B was on the floor on his right side. Resident B stated he is ok. Assisted resident B out of room to a safe location. Resident A has redness noted to R (right) cheekbone and R lower eye, which is starting to bruise slightly. Offered ice pack to resident for face. Will continue to monitor all of these resident closely for next 72 hours. Family, MD and social services aware. f. On 7/26/18 at 9:35 PM, 1930 (7:30 PM) This nurse heard someone yell 'knock it off.' I turned and looked down the hall toward the dining room and this Resident and the resident from room [ROOM NUMBER]-D were hitting each other's heads with their fists closed. This nurse ran down the hall yelling for them to stop which they did. When asked what happened this resident stated 'She is crazy!' When this nurse educated both resident that they are not to be hitting anyone this resident stated 'I know. I am sorry. It is just that when someone hits me its my instinct to hit back.' The resident from room [ROOM NUMBER]-D mumbled something under her breath and walked away. No injuries noted on either Resident. No further issues noted. g. On 7/29/18 at 6:17 PM, This nurse heard CNA yell and when I looked down the hall the Resident from room [ROOM NUMBER] fell to the ground. CNA reported that this (sic) she was grabbing at this Resident's hands. He got mad and shoved her and she fell . This nurse educated resident that he absolutely can not shove or hit other resident. He stated 'she started it and I just reacted.' No injuries noted to either party. Staff has monitored both residents closely and intervened as needed. h. On 8/15/18 at 2:03 PM, Res (resident) 2 was sitting in (sic) Res 1's (this resident) on the recliner. Res 1 was sitting on his bed. The door to the hallway was open. Nurse heard yelling coming from room. Nurse went in to find both residents standing on their feet arguing. Nurse took Res 2 away from Res 1, to Res 2 room. Res 1 states 'she hit me in the arm and I hit her back. I didn't do it hard, I didn't want to hurt her, but I want to protect myself' Nurse assessed Res 1, no injuries to arm, and no injuries to left hand that punched the other resident. Res denied any pain. i. On 8/16/18 at 12:43 PM, PT to discharge to (another facility) at approximately 1300 (1:00 PM). Review of a facility log titled, State of Utah Abuse Reporting Log revealed there were no reported incidents from 4/23/18 until 8/11/18. The resident to resident altercations in the above nursing progress notes for resident 8 were not on the log. (Note: Review of the State Agency's records revealed that none of the above incidences had been reported to the State Agency.) 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 9/5/18. Resident 4's incident reports were reviewed and revealed the following entries: a. On 6/28/18 at 7:30 PM, Resident (Res 1) was sleeping in bed when another resident (Res 2) entered into Res 1 room. Res 1 got out of bed and started shouting at Res 2 which made Res 2 shout back. Staff quickly went into room. Staff witnessed Res 1 punched Res 2 in the chest which made him step back to hit the wall. Res 2 skimmed Res 1 on the arm, no redness or bruising noted to arms. Staff separated resident's immediately taking Res 2 out of Res 1 room. BP (blood pressure) 140/90 HR (heart rate) 84 RR (respiratory rate) 18. Stated no pain at this time. Stated another 'man came into his room and he can't hear so he punched him' Stated 'no new pain and that the man did not hit him.' b. On 7/13/18 at 5:14 PM, Another resident wandered into residents room. Resident does not like this, became very upset, grabbed other resident by the left arm and started punching him in the back. Residents were separated. No injuries noted. c. On 7/19/18 at 9:40 AM, This report is for resident [NAME] Resident B ambulated into residents A's room, this upset resident A and resident A tried to push the resident B out of the room, which evidently pushed resident B to the floor. Resident C stepped into the room from hall to get between theses residents A and B and resident C punched this resident A in the face when nurse entered room resident A was standing with aide assisting to calm him, resident B was on the floor on his right side. Resident B stated he is ok. Assisted resident B out of room to a safe location. Resident A has redness noted to R cheekbone and R lower eye, which is starting to bruise slightly. Offered ice pack to resident for face. Will continue to monitor all of these residents closely for next 72 hours. Family, MD (medical doctor) and social services aware. d. On 7/29/18 at 12:30 PM, This nurse walked into room # 5 to complete treatment on this resident. I found this resident #2-D laying across his bed and he was naked from the waist down, sitting on top of her, bending down to kiss her. This nurse yelled for him to stop and told him to get off of her. He refused. I yelled for help and 2 CNA came in. This nurse informed him that he needed to get off of her, that she was not able to give consent due to her dementia and he stated 'Yes she can.' This nurse then told him again to get off of her, that he did not have the right to do this and he stated 'yes, I do.' This nurse and one CNA assisted him off of her while the other CNA got this (sic) her off the bed. Resident #2-d's brief was still in place and pants were still on. Shirt was still in place. She did not seem in any distress and made no complaints. CNAs assisted her back to her room and into bed to rest. Call light is within reach. This nurse educated Resident that this behavior is unacceptable. Resident was angry and yelled for this nurse to 'get out'. When this nurse told him he was not allowed to do this he stated 'yes I can.' e. On 8/16/18 at 10:28 PM, RN (Registered Nurse) was walking out of another residents (sic) room and CNAs were walking out of shower room when resident pushed another resident out of his room and knocked the resident onto the floor. Other resident was helped up and assisted by the CNAs to the nurse station. Resident was talked to about asking for help when someone goes into his room. He stated he got slapped by the resident and was upset. RN reminded to call for help to prevent any further incidents from happening. Review of a facility log titled, State of Utah Abuse Reporting Log revealed there were no reported incidents from 4/23/18 until 8/11/18. The resident to resident altercations in the above incident reports for resident 4 were not on the log. (Note: Review of the State Agency's records revealed that none of the above incidences had been reported to the State Agency.) 3. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 9/5/18. Incident reports for resident 5 were reviewed and revealed the following: a. On 4/23/18, Aids (sic) found resident laying in bed under the covers with another resident. Resident had all her clothes on. Pt (patient) has no signs of distress. Other resident had pants and underwear off. (Note: This report was on the facility's abuse reporting log, but had not been reported to the State Agency.) On 9/5/18 at 2:29 PM, an interview with the Resident Advocate (RA). The RA stated that she was filling in for the Social Worker who was on maternity leave. The RA stated that she started as the RA on 7/17/18. The RA stated that she had not developed interventions after resident to resident altercations. The RA stated that after altercations between residents the management team had a meeting to discuss what happened, as well as new interventions to prevent another incident. The RA stated that when there was a concern regarding resident to resident altercation, she reported the altercation to Adult Protective Services (APS) which was the State Agency. The RA stated that she was not aware that the State Agency was different from APS. The RA then confirmed that she had not made a separate phone call to the State Agency to report the incidences because she had misunderstood. | 2020-09-01 |