The findings of the complaint health survey (Intake #26303) conducted 3/8/21 through 3/16/21 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 residents. The facility had a census of 47 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
DNS: Director of Nursing Services
F: Fahrenheit
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PRN: as needed
PT: Physical Therapist
qd: every day or daily
qid: four times a day
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietitian
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
UTI: urinary tract infection
The findings of the health complaint revisit survey conducted on 4/30/21 are documented in this report. The facility was found to be in substantial compliance with requirements for Long Term Care Facilities, 42 CFR Part 483.
Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#1) reviewed for potential abuse. This placed residents at risk for potential abuse. Findings include:
The facility's 9/2017 Abuse Prevention, Intervention, reporting and Investigation Policy and Procedure indicated the following:
-Residents will be free from abuse, including verbal, mental, sexual or physical abuse, corporal punishment, involuntary seclusion, mistreatment and neglect.
Resident 1 was admitted to the facility on 8/2020 with diagnoses including dementia with behavioral disturbance, spinal stenosis (narrowing of spinal canal), anxiety and depressive disorder. Resident 1 had a BIMS (Brief Interview Mental Status) score of 13, obtained from the MDS quarterly report dated 11/29/20, indicating moderate cognitive impairment, but was able to make her/her needs known and direct her/his own care.
Resident 1's care plan revealed she/he was incontinent of bladder and bowel, often refused bowel care and declined other care such as bathing. Interventions were to report refusals of care to the licensed nurse, reapproach resident with another staff and report any other concerns to the charge nurse, Executive Director (ED) or Director of Nursing Services (DNS).
On 9/2/21, the facility submitted a Facility Reporting Incident (FRI) indicating Resident 1 had been abused by Staff 7 to the state agency (#26303).
A written statement from Staff 8 (Licensed Nurse) on 9/2/20 regarding the abuse incident revealed:
-Staff 8 had responded to Resident 1's call light at approximately 6:00 PM. The resident informed Staff 8 she/he had not had a brief change for a while and was wet. Staff 8 told Resident 1 that meal trays would need to be delivered in order to prevent the food from getting cold, then the resident's brief would be changed.
-Staff 7 (Former CNA) reported to Staff 8 she had delivered the meal tray to Resident 1's room around 6:30 PM. Resident 1 again requested that her/his brief be changed but was told by Staff 7 it would be later. At approximately 7:30 PM, Staff 7 went back into Resident 1's room and Resident 1 told Staff 7 that she/he was still waiting for a brief change and also had a bowel movement since Staff 7 had been in the room. Staff 7 told the resident that she would be back after she finished collecting meal trays and left.
-Staff 8 went into the resident's room at Staff 7's request and spoke to her/him. Staff 7 stood outside Resident 1's room, overheard the conversation, went back in and engaged in a "back and forth" conversation with the resident . Staff 8 asked Staff 7 to exit Resident 1's room. Staff 8 told the resident she would get another staff member to change her/his brief.
A written statement from Staff 2 (DNS) on 9/4/20 regarding the abuse incident revealed:
-On 9/1/20, Resident 1 and Staff 8 reported the resident was left in a dirty brief for more than two hours. When Resident 1 asked to be changed, she/he was told by Staff 7 she had other things to do.
-According to Facility abuse policies, Staff 7 neglected Resident 1 by leaving Resident 1 in a brief after a bowel movement. Staff 7 was terminated and facility reported to the appropriate state agencies.
A "Final Summary: Allegation of Abuse" report written by Staff 1 (Administrator) on 9/3/20 revealed:
-Resident 1 notified Staff 3 (RNCM) she/he had sat in a bowel movement for three hours and had been told by Staff 7 she had other things to do when the resident requested a brief change.
-Staff 7 was placed on administrative leave and Staff 8 confirmed the statement she had written regarding Resident 1 and the allegations of abuse by Staff 7. The report also stated Staff 8 would be provided with disciplinary action and education.
Observations of Resident 1 were made on 3/8/21 and 3/9/21 in the facility, over day and evening shifts. Resident 1 was observed to remain in her/his room and occasionally conversing with staff.
On 3/8/21 at 4:13 PM, Resident 1 stated there had been a lot of incidents at the facility concerning her/his care. Resident 1 was unable to recall the 9/1/20 incident.
On 3/12/21 at 3:45 PM, Staff 8 (LN) confirmed written statement, confirmed she had requested staff change assignments at 8:15 PM with another staff for Resident 1's care.
On 3/15/21 at 3:00 PM, Staff 7 (Former CNA) stated on 9/1/20 (evening shift) she had no assistance with passing dinner trays or responding to call lights. Around 6:00 PM, Staff 8 told Staff 7 Resident 1 had urinated, but was fine with waiting for Staff 7 to pass the meal trays. Staff 7 continued to pass meal trays and complete other care tasks.
Staff 7 returned to Resident 1's room after 7:00 PM. Resident 1 was livid, screaming Staff 7 neglected her/him, didn't change the resident's brief and the resident had a bowel movement as well. Staff 7 let the resident know that she was was still working on getting the trays collected, the other residents had to get their needs met and said she was doing her best. Resident 1 continued to complain to Staff 7, who admitted she did get upset and firmly let the resident know that she "did not have to take this" and left the resident's room.
Staff 7 stated she stayed outside Resident 1's room when Staff 8 went into the room because she wanted to hear what Resident 1 said and heard Resident 1 complaining about other things not related to the incident. Staff 7 admitted going back into Resident 1's room, spoke briefly to the resident, then left the room. Staff 7 later observed another CNA go into Resident 1's room to change the resident's brief. Staff 7 stated it was almost 8:00 or 9:00 PM at this point.
On 3/16/21 at 9:48 AM, Staff 2 (DNS) confirmed the report she prepared regarding the abuse incident was correct and Staff 7 did not deny she had abused Resident 1.
Staff 2 confirmed it is an expectation that residents have their briefs changed in a reasonable amount of time.
On 3/16/21 at 10:53 AM, Staff 1 (Administrator) confirmed the report she prepared regarding the abuse incident was correct.
Staff 1 confirmed it is an expectation if a resident had a bowel movement, their briefs should be changed before meal trays are picked up.
F 600 Free from Abuse and NeglectCFR(s): 483.12(a)(1) Resident Specific:Resident #1 has been reviewed to ensure they are free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, physical and/or chemical restraint including freedom verbal, mental, sexual, and physical abuse in order to avoid placing them at risk for potential abuse.Other Residents:The Executive Director, Director of Nursing and/or designee has reviewed other residents to ensure they are free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, physical and/or chemical restraint including freedom verbal, mental, sexual, and physical abuse in order to avoid placing them at risk for potential abuse.Facility Systems:Facility staff have been re-educated on ensuring their residents are free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, physical and/or chemical restraint including freedom verbal, mental, sexual, and physical abuse in order to avoid placing them at risk for potential abuse.Monitor:The Executive Director and/or designee will monitor staff/residents to ensure they are free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, physical and/or chemical restraint including freedom verbal, mental, sexual, and physical abuse in order to avoid placing them at risk for potential abuse a minimum of 5 times weekly for four weeks and weekly for 2 months. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the Executive Director and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: April 15, 2021Person Responsible: Executive Director and/or designee.
The findings of the complaint health survey (Intake #26303) and conducted 3/8/21 through 3/16/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 3/16/21.
The sample was comprised of four residents. The facility had a census of 47 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
DNS: Director of Nursing Services
F: Fahrenheit
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PRN: as needed
PT: Physical Therapist
qd: every day or daily
qid: four times a day
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
UTI: urinary tract infection
This report reflects the findings of the state licensure revisit survey conducted on 4/30/21. The facility was found to be in substantial compliance with OAR 411 Divisions 85 through 89.
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OAR 411-085-0362 Freedom From Abuse, Neglect and Exploitation
Refer to F600
