| 10 |
SEA VIEW NURSING HOME |
485000 |
7500 BOLONGO BAY |
ST THOMAS |
VI |
802 |
2013-09-13 |
226 |
G |
0 |
1 |
IBTI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility complaints and investigations, and resident and staff interviews, it was determined that the facility failed to protect 1 of 14 residents (Resident #7) from physical abuse inflicted by staff and that caused the resident to sustain an injury. The findings are: Resident #7 is a [AGE] year old female diagnosed with [REDACTED]. Nursing Monthly Summary Assessments dated 7/1/2013, 8/1/2013 and 9/1/2013 indicate the resident is alert but confused, speaks incoherently, and requires assistance with transfers. The resident is non-ambulatory and uses a wheelchair. A complaint investigation dated 8/28/2013 identifies the resident as a victim of physical abuse. During review of the resident's medical record a nursing note documented on Clinical Notes dated 8/22/2013 at 5:30 P.M. were observed to read: I was made aware of a small cut to the resident's forehead. The area was cleaned ad a bandage applied; Incident report written. A second entry written for 1-3:00 A.M., reads: Met resident in bed asleep .bandage to forehead, slight swelling noted. A review of an Incident Report dated 8/22 /2013 reveals the resident sustained [REDACTED]. The incident report provides the following description of occurrence: A fight between two employees; Resident # 7 was found with a small cut to the forehead. Area was cleaned and antibiotics applied and covered with a bandage. An investigative Report dated 8/28/2013 summarizes the incident as follows: On August 22, 2013, it was reported that there was an altercation between a CNA and a housekeeper which started as a result of a resident's family member asking to have some fruit placed in the refrigerator. According to witnesses of the incident, the CNA questioned whether or not the fruit was labeled. The housekeeper said yes, they were, and felt that the CNA was harassing her. According to the LPN Charge nurse, she overheard the housekeeper asking the CNA to excuse (move away from) behind the nursing station in order for her to sweep and mop. The CNA was asked three times and refused to move until the nurse intervened and ordered her to move. The CNA left from behind the nurse's station and the housekeeper proceeded to sweep. At the same time the phone rang and the housekeeper answered it. The CNA told her not to answer the phone again and proceeded to pull the phone away from the housekeeper. In the altercation of the phone incident, a resident was physically hurt. She received a blow to the forehead which left a red mark and a small amount of swelling. The resident was immediately removed from the scene while the two staff members continued to fight. Further investigation with the evening shift revealed that both employees were arguing before the fight occurred. During an interview with the facility ' s administrator conducted 9/12/2013 at 1:15 P.M., the administrator stated that she made a thorough investigation of the incident and both parties admitted that they were fighting which is against the facility ' s policy. The fighting occurred in front of residents and Resident #7 was hurt. The administrator also stated that it is the Nursing Home's policy that fighting in the work place will not be tolerated and if a resident is hurt in the process of employees fighting, it will be considered physical abuse of that resident. The administrator stated both employees admitted to hitting the resident with the phone during the fight which caused swelling and a red mark to the Resident's forehead. The administrator also stated that she has had problems with these two employees in the past. The Housekeeping Director was interviewed on 9/12/2013 at approximately 3:00 P.M. and reported during the interview that the housekeeper involved in the fight was a problem and had been a problem for a long time. He stated the employee was difficult to manage, would not follow orders, and did whatever she wanted. He further stated that the she (the housekeeper) has been involved in a previous incident of verbal fighting that occurred with another staff member right outside of resident rooms. He stated the housekeeper was screaming out derogatory words and everyone including the residents could hear her. She thinks she can do whatever she wants because she's worked here for so long. During the resident Group Meeting held 9/10/2013, when residents were asked about incidence of abuse, one resident in the group, Resident #14 reported that about three weeks ago, he observed a fight between two of the staff that occurred at the nurse's station. An individual interview was held with Resident #14 on 9/12/2013 at 10:30 A.M. The resident reported that during the fight he witnessed between the two staff members about three weeks ago, a resident who was sitting in a wheelchair near the nurse's station was hurt when she was hit in the head with the telephone. The resident stated the staff was fighting over the telephone. He said he was not the only one to witness the incident. Everyone saw it. Personnel files of the CNA and Housekeeper were reviewed on 9/12/2013. Each file revealed a history of multiple incidents of violent verbal behavior. Disciplinary Notices that were found in the CNA's file indicate the CNA was counseled for verbal abuse and use of profanity in front of residents on several occasions from 5/10/07 through 4/28/12. On 5/14/07, the CNA was counseled and received a Letter of Warning for an act of insubordination and abusive behavior directed at a Charge Nurse occurring at the Nurses' station 5/10/07. On 11/23/09, she was counseled for verbal abuse and harassment of other employees /coworkers. On 1/27/10, she was counseled for Job and resident abandonment and on 5/31/11 she was counseled for becoming irate and verbally assaulting the Administrator during a staff meeting. A warning notice, documented by the Director of Nurses, reveals that on on 5/31/11, the CNA was on sick leave. She was, however, in the facility and decided to attend the monthly staff meeting. During the course of the discussion, she became very irate and began a verbal assault on the Administrator. I immediately informed her that her behavior was unacceptable and disrespectful to the Administrator as well as all others in attendance and would not be tolerated. She was asked to cease the behavior, but instead, her behavior escalated and her tirade of negative remarks continued. This resulted in disruption of the staff meeting. She was then asked to leave the meeting and the facility but did not do so until she was finished with her verbal assault. I have spoken with the CNA on several occasions regarding her inappropriate behaviors - specifically outbursts that have incited the staff. She has been asked to discuss any matters which she is not in agreement with instead of making negative comments or engaging in loud outbursts in the presence of everyone. In spite of this, she continues to do so. A disciplinary action notice dated 3/14/2012 documented by the Director of Nursing reveals that on 3/8/12, outside the door of a resident 's room, and within hearing distance of residents, the CNA and another housekeeper verbally abused each other with derogatory terms. Letters warning of suspension and /or termination are documented in this employee file for each incident since the initial episode that occurred in 2007. There was no evidence found in the CNA's file to indicate that either of these interventions was implemented. A Review of the Housekeeper's personnel record reveals that she was initially hired as a cook in 1998 was terminated in 1999 for insubordination and serving residents improperly cooked food (raw food), was rehired as a laundry attendant and subsequently transferred to housekeeping. She has received the following Disciplinary Action Notices since her date of hire and prior to the violent physical incident that occurred on 8/22/2013: On 2/22/1999 she was counseled for insubordination and unsafe food preparation. Documentation on a Performance Improvement Disciplinary Action Plan dated 4/8/99 indicates that on 3/26/1999 and 3/28/1999 the employee committed various food handling infractions which presented a health risk to residents. The problems have been continuous as documented on 2/22/99 and 3/23-3/24/2099. Ongoing counseling has been provided to the employee since 1/25/99. On 4/13/1999, the employee received a Personnel Action Termination Notice indicating she is not appropriate for Dietary Services. On 5/22/2001, the employee was counseled for improperly cleaning resident rooms. On 1/9/2002 the employee received a verbal warning for insubordination when she refused to participate in an investigation of resident abuse and neglect. 3/7/2002, a Suspension Notice was given the employee for insubordination when she refused to participate in an investigation of misappropriation of resident's property. 1/13/2010, the Housekeeper was counseled for a violent verbal outburst occurring within the vicinity of resident rooms. A description of this incident is reported by a witness on a document titled Afternoon Disturbance and reads Yesterday, while completing some work on the computer in the MDS room, I heard some loud noise coming from outside. I ignored it for a few minutes until the yelling was getting louder and louder, and at this time heading toward the B Wing where the residents reside. I took a glance outside and saw the Housekeeper loudly cursing and repeatedly saying ya'll please leave me alone. I then addressed her and asked her to lower her tone. The noise down the hallway was definitely disturbing the residents. At that point she asked me to mind my business and leave her alone. I then told her that whatever issue she has, it doesn ' t need to affect those who reside here. Again, she got louder and I resorted to closing the MDS door. Other staff members were asking her to lower her voice, but she just kept getting louder. On 11/30/2010, a Verbal Warning was given for time fraud. ON 12/8/2010, a Written Warning and counseling was given for insubordination and the use of disrespectful language when speaking to her supervisor. On 1/12/2011, the employee received a written warning for an incident of Violent Verbal outbursts that occurred in the presence of residents and was directed at a supervisor. This incident was witnessed by five co-workers who documented the following observations: Witness #1: I was standing at the nurse ' s area when I heard the Housekeeper screaming at the top of her voice, leave me alone! Witness #2: I was in the Nurses ' area when the housekeeper was yelling and making a lot of noise. Ms. ? (Nursing Supervisor) told her to quiet down and she made a remark to her Don't tell me Nothing. She was walking toward the B-Wing and Ms. (Nursing Supervisor) told her to cool down and she made another remark to her saying leave me alone! Witness #3: I was standing at the Nurse's station when I heard the Housekeeper Screaming at the top of her voice, leave me alone. Leave me alone! Witness #4: I found this behavior to be very disruptive and in the presence of residents. I think this needs to be addressed. On 2/8/2011, a Written Warning was given for verbal violence and insubordination by refusing to obey her supervisor directives, engaging in loud arguing with the supervisor and causing a disturbance to residents. The Housekeeper received another Verbal Warning 4/14/2011 for insubordination and refusing to follow her supervisor's orders. This incident was witnessed by two co-workers who documented the following on Witness Statements dated 2/8/2011: Statement#1: On Tuesday, February 8, 2011 at around 2:25 P.M., I was in room A07 (a resident ' s room) cleaning and removing trash from the room when I heard loud arguing on the floor. I came outside the room and I heard the Housekeeper saying to her Supervisor, leave me alone. Don ' t tell me what to do. You don't have anything better to do? Just leave me alone! The Supervisor asked her to please calm down with the loud noise on the floor. She continued to tell him to leave her alone, don't tell me what to do. He repeatedly asked her to stop making noise in the building and she continued in her loud voice, so he walked away. Statement #2: I heard the Housekeeper on the floor saying to leave her alone and she was so loud on the floor. She has no respect for her boss. The Housekeeper received another verbal Warming 4/14/11 for insubordination and refusing to follow her supervisor ' s order. 3/29/2012, a Written Warning was given for verbal abuse directed at another employee, and for using inappropriate language in the resident ' s lounge in the presence of residents. 4/28/2012 the employee was cited for verbal abuse directed at a co-worker and use of profanity in the presence of residents, and on 8/29/2012, a Written Warning was received for violent verbal outbursts and blatant refusal to obey a supervisor ' s orders. In spite of these multiple incidents, the housekeeper remained employed by the facility. The facility ' s Policy for Abuse Prevention includes specific conduct violations that warn its staff of immediate termination. The first violation listed on this Code of Conduct is any verbal or physical abuse to any resident or fell ow employee. This policy was not implemented. In spite of the evidence contained in both employees ' personnel files, they were allowed to continue working until resident # 7 was harmed on 8/22/2013. As a result, the facility was unable to maintain a violence-free workplace, did not protect residents from exposure to violence, and failed to protect one resident from an injury caused by the violent actions of two of its staff. The facility failed to operationalize its Abuse Prevention program. |
2017-01-01 |