The findings of the complaint (Intake #s 27041 and 27365) health survey conducted 1/26/21 through 1/28/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
The sample was comprised of 2 current resident and 3 discharged residents. The facility had a census of 47 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint health survey (Intake #s 27041 and 27365) conducted on 3/8/21 are documented in this report. The facility was found to be in substantial compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Based on interview and record review, it was determined the facility failed to ensure residents were free from verbal abuse for 1 of 5 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include:
The facility's 2/2019 Abuse screening, training, identification, investigation, reporting and protection policy defined verbal abuse as "the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms."
Resident 2 was readmitted to the facility in 9/2020 with diagnoses including alcohol abuse and a neurological disorder. Resident 2 discharged from the facility in 12/2020.
Resident 2's 11/6/20 Quarterly MDS indicated she/he was cognitively intact.
a. An incident report from 10/28/20 indicated Resident 2 was visiting another resident on Resident 1's hall. Resident 1 appeared visibly intoxicated and yelled "Get the hell out of my hall", and called Resident 2 a "stupid [expletive]" and if staff did not make Resident 2 go back to her/his room Resident 1 would "do it [her/his]self". The report indicated staff intervened between the residents. The residents were put on alert charting, care plans were updated, and a one on one staff member (1:1) was assigned to Resident 2 for safety. Resident 2 reported feeling "threatened" but did not engage with Resident 1. Witnesses were identified as Staff 5 (CNA), Staff 6 (RN) and Staff 13 (Social Services Assistant).
Resident 1 and Resident 2 were placed on alert and no further signs or symptoms were documented for changes in behavior or verbal statements related to the incident. Resident 2's behavior log did not indicate changes from baseline.
A nursing note from 11/28/20 indicated Resident 2 had a confrontation with another resident while in the smoking area.
Two incident reports from 11/22/20 and 12/20/20 indicated altercations between Resident 1 and Resident 2 occurred, abuse was ruled out, and care plans and interventions were updated.
On 1/26/21 Resident 1 declined to be interviewed.
On 1/27/21 at 1:57 PM Resident 2 stated Resident 1 waited until staff were not around and "stalked" and "screamed" at her/him. Resident 2 stated she/he stayed in her/his room more often than she/he would have preferred because of Resident 1, but she/he felt safe in the facility most of the time. Resident 2 stated the facility tried to prevent Resident 1 from "attacking" her/him, but it was not effective. Resident 2 stated the lewd words Resident 1 used towards her/him made the resident feel "hurt".
On 1/27/21 at 1:08 PM Staff 5 (CNA) stated Resident 1 would seek out Resident 2 anytime Resident 1 saw Resident 2 and frequently called Resident 2 expletive names. Staff 5 stated Resident 1 yelled at staff if they tried to redirect her/him. Staff 5 stated Resident 2 was fearful of Resident 1 and stayed in her/his room if Resident 1 was in the hallway.
On 1/27/21 at 2:39 PM staff 6 (RN) stated Resident 1 often yelled extreme profanities at Resident 2. Staff 6 stated Resident 2 reported to her she/he was fearful at times but would go out to the smoking area even if Resident 1 was there. Staff 6 stated Resident 2 never appeared frightened to her and the resident seemed to go to the smoking area to "passively antagonize" Resident 1.
On 1/28/21 Staff 7 (CNA) stated Resident 1 "targeted" Resident 2 and Resident 1 yelling expletives at Resident 2 was an "ongoing issue". Staff 7 stated Resident 2 "hid" in her/his room and asked everyone if Resident 1 was around before coming out.
On 1/28/21 at 12:08 PM Staff 3 (Social Services) acknowledged verbal abuse by Resident 1 towards Resident 2. Staff 3 stated she never witnessed any verbal abuse, but Resident 2 and staff reported when it happened and interventions and changes to the care plan were put in place to prevent further altercations. Staff 3 stated Resident 1 and Resident 2 declined mental health services.
b. A 10/23/20 at 11:52 PM nursing note indicated at 7:30 PM that evening Staff 9 (RN) was giving Resident 2 her/his medication when Resident 1 told Resident 2 to "put your [expletive] mask back on". The note stated the incident brought Resident 2 "to tears" as Resident 2 stated Resident 1 also called her/him a lewd name as Resident 1 wheeled back to her/his room.
A 10/23/20 late entry social services note indicated Resident 2 stated Resident 1 continued to make negative statements toward her/him and stated that evening, "Why don't you go and tell [Staff 3, Social Services] I called you a [expletive] again because that is what you are, a [expletive]."The note stated the DNS and Administrator were made aware of the incident and care plan interventions to separate the residents were implemented.
Resident 2's clinical record indicated no further signs or symptoms were documented for changes in behavior from baseline.
On 1/27/21 at 1:57 PM Resident 2 stated she/he stayed in her/his room more often than she/he would have preferred because of Resident 1, but she/he felt safe in the facility "most of the time." Resident 2 stated the facility tried to prevent Resident 1 from "attacking" her/him, but it was not effective. Resident 2 stated the lewd words Resident 1 used towards her/him made the resident feel "hurt".
On 1/28/21 at 12:08 PM Staff 3 (Social Services) stated Resident 2 reported verbal abuse on 10/23/20 by Resident 1. Staff 3 stated the resident was tearful in her office, but the resident was tearful per baseline. Resident Staff 3 stated administrative staff discussed the incident but did not formally investigate or report the alleged abuse due to no physical altercation. Staff 3 stated updated interventions were put in place for Resident 1 and Resident 2 to prevent further altercations and acknowledged altercations continued despite the interventions.
On 1/28/21 at 1:14 PM Staff 9 (RN) stated on 10/23/20 Resident 1 muttered something "under [her/his] breath" while wheeling past Resident 2. Staff 9 could not hear the statement but Resident 2's reaction was "severe" and she/he told Staff 9 Resident 1 called her/him a [expletive] before yelling about the mask. Staff 9 confirmed Resident 2 was tearful directly after the incident. Staff 9 stated she did not report the incident to anyone, and Resident 1 had a history of yelling expletive comments at Resident 1.
On 1/28/21 at 1:32 Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the incident on 10/23/20 and stated an investigation was not completed to rule out verbal abuse.
Refer to F610
F6001. The residents identified, both of them, as Resident 1 and Resident 2 have been discharged.2. All residents have the potential to be affected by this deficient practice.3. All staff will be retrained on abuse and neglect policy and resident rights. All residents will have an updated information session on abuse and neglect, as well as resident rights. Residents will be educated again on how to utilize the grievance process, as well.4. The facility will ensure compliance by auditing grievances two times per week to ensure compliance. The facility will, additionally, conduct random interviews with five residents per week in regards to abuse and neglect. These audits are designed for three weeks.5. The person responsible will be the Administrator and/or Designee.6. Date of Compliance: 2/26/2021
Based on interview and record review it was determined the facility failed to investigate allegations of verbal abuse for 1 of 5 sampled residents (#2) reviewed for abuse. This placed residents at risk for mental anguish and psychosocial decline. Findings include:
The facility's 2/2019 Abuse screening, training, identification, investigation, reporting and protection policy defined verbal abuse as "the use of oral, written or gestured communication to a resident or visitor that describes a resident(s) in disparaging or derogatory terms."
The facility's 2/2019 Accident/Incident policy indicated "all resident to resident altercations require an incident investigation to be started for each resident, regardless of whether the altercation was physical, verbal or attempted...if in doubt about what constitutes an incident, fill out the report."
Resident 2 was readmitted to the facility in 9/2020 with diagnoses including alcohol abuse and a neurological disorder.
A 10/23/20 at 11:52 PM nursing note indicated at 7:30 PM Staff 9 (RN) was giving Resident 2 her/his medication when Resident 1 told Resident 2 to "put your [expletive] mask back on". The note stated the incident brought Resident 2 "to tears" as the resident stated Resident 1 also called her/him a lewd name as Resident 1 wheeled by.
A 10/23/20 late entry social services note indicated Resident 2 stated Resident 1 continued to make negative statements toward her/him and stated that evening "Why don't you go and tell [Staff 3, Social Services] I called you a [expletive] again because that is what you are, a [expletive]." The note stated the DNS and Administrator were made aware of the incident and care plan interventions to separate the residents were implemented.
On 1/28/21 at 12:08 PM Staff 3 (Social Services) stated Resident 2 reported verbal abuse on 10/23/20 by Resident 1. Staff 3 stated administrative staff discussed the incident but did not formally investigate or report the alleged abuse due to no physical altercation. Staff 2 stated updated interventions were put in place for Resident 1 and Resident 2 to prevent further altercations
On 1/28/21 at 1:14 PM Staff 9 (RN) stated on 10/23/20 Resident 1 muttered something "under [her/his] breath" while wheeling past Resident 2. Staff 9 could not hear the statement but Resident 2's reaction was "severe" and she/he told Staff 9 Resident 1 called her/him a [expletive] before yelling about the mask. Staff 9 confirmed Resident 2 was tearful directly after the incident. Staff 9 stated she did not report the incident to anyone, and Resident 1 had a history of yelling expletive comments at Resident 2.
On 1/28/21 at 1:32 Staff 1 (Administrator) and Staff 2 (DNS) acknowledged an investigation was not completed and the 10/23/20 incident was not reported for the allegation of verbal abuse.
F6101. The residents identified, both of them, as Resident 1 and Resident 2 have been discharged.2. All residents have the potential to be affected by this deficient practice.3. All staff will be retrained on abuse and neglect policy and resident rights. All residents will have an updated information session on abuse and neglect, as well as resident rights. Residents will be educated again on how to utilize the grievance process, as well. Additionally, the administrator will be retrained on appropriate reporting and requirements under state law.4. The facility will ensure compliance by auditing grievances two times per week to ensure compliance. The facility will, additionally, conduct random interviews with five residents per week in regards to abuse and neglect. These audits are designed for three weeks.5. The person responsible will be the Administrator and/or Designee; retraining of the administrator will be conducted by the Vice President of Operations.6. Date of Compliance: 2/26/2021
The findings of the complaint (Intake #s 27041 and 27365) health survey conducted 1/26/21 through 1/28/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89. For additional information refer to the Form CMS 2567 dated 1/28/21.
The sample was comprised of 2 current resident and 3 discharged residents. The facility had a census of 47 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
SLP: Speech Language Pathologist
TAR: Treatment Administration Record
tid: three times a day
UA: Urinary Analysis
UTI: Urinary Tract Infection
The findings of the revisit complaint health survey (Intake #s 27041 and 27365) conducted on 3/8/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
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OAR 411-085-0360 Abuse
Refer to F600 and F610
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