HospitalInspections.org

Based on interview and record review, the facility failed to ensure swing bed patients were free from physical abuse which affected 2 (#s 1 and 7) of 7 sampled patients. Findings include:

1. During an interview on 12/27/18 at 1:50 p.m., staff member A stated she had witnessed patient #1 grab the arm of patient #7 causing patient #7 to cry out in pain when patient #7 was ambulating past patient #1 in the hallway. Staff member A stated the incident was reported to the DON and an incident was filed in patient #1's medical record. Staff member A stated patient #1 frequently complained of left arm pain and accused patient #7 of "hitting his arm" which had not been witnessed. Staff member A stated patient #7 was only "shook-up" over the incident and the staff member could not recall if an incident was filed in patient #7's medical records.

Patient #1 was admitted to the facility with diagnoses including right basal ganglia hemorrhage with mass effect in the right lateral ventricle with subsequent craniotomy and hematoma evacuation in November 2016, left hemiparesis, and cognitive and self-care impairment.

During an interview and record review on 12/27/18 at 2:00 p.m., staff member G stated an incident involving patient #1 had been recorded in the facility's Abuse Log. Staff member G stated she had not been employed at the facility at the time of the incident, but assumed a report had been filed with the State Agency and a five-day investigation conducted. Staff member G stated she could not locate a reported or investigated incident in the Abuse Log.

During an interview on 12/27/18 at 2:31 p.m., staff member C stated she, along with the DON and Social Services Director, were responsible for initiating, reporting, and investigating actual and alleged allegations of abuse involving patients at the faciltiy. Staff member C stated actual and alleged allegations of abuse were to be reported to the State Agency "with-in a few weeks," and should be investigated "with-in a few weeks" after the incident.

During an interview on 12/27/18 at 3:10 p.m., staff member E stated she had not reported the patient-to-patient abuse incident involving patients #1 and #7. Staff member E stated the incident had not been reported to the State Agency and a five-day investigation not conducted.

During an interview on 12/27/18 at 3:21 p.m., staff member D stated she was not aware an incident of [physical] abuse involving a resident-to-resident should be reported to the State Agency and investigated by the facility. Staff member D stated "this type of abuse was new" to her.

A review of patient #1's Nurse's Note, dated 4/8/18 at 12:55 p.m., read, "At 1230 Resident [sic] was in an altercation with another resident in front of nurse's station. Female resident was trying to get around him so she could get to her room...This resident grabbed female's hand and squeezing it...He also reached out to grab CNA's arm but she was able to get away. Resident let go of female resident's hand and claimed she had hit his upper left arm. This did not happen. Resident claims again that she hit him. He was upset that she was being rude to him by telling him to get out of the way in the manner the female resident spoke to him. This nurse spoke to him about letting older residents go by and sometimes older residents are rude and to just ignore them. He appeared to calm down and went to this room."

A review of patient #1's Nurse's Note, dated 4/10/18 at 11:29 a.m., read, "...This meeting was held because [patient name] has been exhibiting aggressive behaviors towards staff and other residents [sic] of this facility since his arrival. [Patient name] has raised his fist at other residents, has had physical contact with a nurse (punching the nurse in the chest, pinching her and scratching her hard enough to draw blood) and most recently made physical contact with a 90 year old resident [sic] by grabbing her hand and squeezing it until she cried out..."

A review of patient #1's Progress Note, dated 5/10/18 at 5:08 p.m., read, "...Over the past few months he has had extremely aggressive behaviors...We have documented multiple episodes at which he made actual attempts to injure staff members and did indeed injure in a minor way scratching attendants until blood was drawn. He also made an attempt to injure fragile elderly residents [sic]of the nursing home facility at various times..."

A review of facility reported incidents' failed to show a report had been submitted to the State Agency. A five-day investigation was requested but not submitted prior to the exit conference with the facility staff.

2. During an interview on 12/27/18 at 4:30 p.m., patient #7 stated she could not recall an incident where patient #1 had squeezed her hand until she cried out, but remembered patient #1 was at the facility "a long time ago."

Patient #7 was admitted to the facility with diagnoses including congestive heart failure and atrial fibrillation. She was alert and oriented to person, place, and time.

A review of patient #7's nursing notes and progress notes, dated 4/6/18 through 5/14/18, lacked evidence showing an incident report had been filed with the State Agency regarding an incident involving patient #1 "grabbing" the resident's [sic] arm/hand. Facility staff did not assess patient #7 for injuries and did not conduct a five-day investigation follow-up.

A review of the facility's policy, Abuse Reporting Requirements, revised 6/4/14, read, "[Facility name] is required to report all alleged violations involving mistreatment, neglect , abuse, including injuries of unknown source, and misappropriation of patient property to the Department of Public Health and Human Services [DPHHS]...4. Physical Abuse- includes hitting, slapping, pinching and kicking..."

A review of the facility's policy, Abuse Investigation, revised 6/4/14, read, "1. When an incident or suspected incident of abuse is reported, the Chief Executive Officer (CEO) will appoint a representative to investigate the incident. An initial call will be made to the (DPHHS) that an abuse investigation is taking place immediately or within twenty-four (24) hours...2. The investigation results will be sent to the [DPHHS] with in five (5) working days."

A review of the facility's policy, Abuse Prevention, read, "...10. Facility staff shall recognize abuse when it occurs and when, what and to whom to report."