Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to notify the Physician when a medication was unavailable for several days for 1 Resident (#8) out of a total sample of 24 residents.

Findings include:

Resident #8 was admitted to the facility in 12/2011 with [DIAGNOSES REDACTED]. Review of the 3/2017 Medication Administration Record [REDACTED]. Further review indicated the medication was circled as not being given from 3/1/17 (9:00 P.M. dose) thru 3/5/17, missing a total of 8 doses. Documentation on the backside of the MAR indicated [REDACTED].

Review of the Progress Notes from 3/1/17-3/5/17 indicated the Physician or Nurse Practitioner (NP) was not notified that the Resident had not received the [MEDICATION NAME] as ordered. During an interview on 3/24/17 at 11:45 A.M., Nurse #2 said the [MEDICATION NAME] wasn’t available at the start of the month and she contacted the pharmacy to reorder it. She said she hadn’t notified the Physician or NP about the Resident not receiving the [MEDICATION NAME] as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to properly investigate an allegation of abuse for 1 Resident (#4) and failed to complete two investigations related to bruises of unknown etiology for 1 Resident (#16) out of a total sample of 24 residents.

Findings include:

Review of the facility Policy for Abuse and Prohibition, effective 4/10/03 and revised 2/28/17, indicated the following:

a. Purpose- The purpose is to protect the resident from verbal, sexual, physical, and mental abuse by anyone including but not limited to, staff, other residents, consultants or volunteers, staff from other agencies, family members or legal guardians, friends, or other individuals.

b. Physical abuse- includes hitting, slapping, pinching, kicking .

c. Identification- all incidents of unexplained or questionable injury such as bruising, will be investigated in order to identify potential abuse or mistreatment.

d. Investigation and Reporting- Anyone who witnesses .or has received a complaint of abuse from a resident or family member is required to report it immediately to the nursing supervisor.

-The nursing supervisor (or designee) will be responsible for completing an incident report and beginning an investigation.

-The Administrator or Director of Nurses (or designated individual) will conduct a thorough investigation of the allegation. The investigation will include interviews with victim, staff, residents, or anyone else involved with or having knowledge of the event.

-The investigation will be completed in written detail with signed individual statements from all individuals or interviewers.

1. Resident #4 was admitted to the facility in 10/2014 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 9/13/16, indicated the Resident had moderate cognitive deficits with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review indicated he/she had no mood issues and his/her Health Care Proxy (HCP) was not invoked.

Review of the SBAR Progress Note, dated 12/4/16, indicated the Resident reported he/she had been punched in the stomach. The Resident complained of an upset stomach and then told the nurse,it started after that girl punched me in the stomach this morning. The Resident went on to say that he/she was half asleep when the girl came in and woke the Resident up by punching him/her in the stomach. The nurse wrote that the Resident repeated the story multiple times to multiple people. Further review indicated the nursing supervisor was contacted to initiate an investigation, and the Director of Nurses (DON) was also notified.

Review of a statement written by Nurse #4, dated 12/4/16, indicated that she was supervising the dining room that morning when the Resident requested crackers for an upset stomach that was caused by being punched in the stomach. Nurse #4 went to speak to the nurse who had worked the 11:00 P.M.- 7:00 A.M. shift and that nurse reported she was aware and had looked into it.

Review of the Progress Note, dated 12/6/16, indicated the DON met with the Resident on 12/5/16 and the Resident denied stomach pain. The Resident was able to give vague recall related to an incident over the previous weekend but was unclear to the exact details. Review of the Progress Note, dated 12/7/16, indicated the Social Worker met with the Resident on 12/6/16 with the family present.

The Resident greeted the SW by saying I bet I know why you’re here then proceeded to tell the SW that someone punched him/her in the stomach. Family reported the Resident told them the same thing. Resident was unable to provide details of the allegation, family reported to SW that Resident had made similar allegation in the past but found no basis for the allegation. Further review of the note indicated the facility staff planned to have HCP invoked. Review of the Nurses Progress Note, dated 12/7/16 (11:00 P.M.-7:00 A.M.) indicated a nursing entry in response to SBAR submitted 12/4/16. Further review indicated the Resident had reported being punched in the stomach to the nurse, the Resident reportedly said he/she didn’t know if the person was a male or female. The nurse assessed the Resident for injury and found none. Further review indicated the nurse did not report the allegation to the nursing supervisor and did not initiate an investigation. The Resident did not report stomach pain/gastro intestinal upset at that time. Review of the current care plan did not indicate the resident had a history of [REDACTED].

Review of the Incident/Accident report did not indicate which staff were on duty for the 11:00 P.M.-7:00 A.M. or the previous 3:00 P.M.-11:00 P.M. shifts. Also, it did not indicate which staff were interviewed, when they were interviewed, and what specifically was said as there were no written statements provided by the facility upon the surveyor’s request.

During an interview on 3/24/17, in the presence of another surveyor, the DON and Administrator both said they had talked to staff regarding the allegation of abuse made on 12/4/16. They said they talked to the 11:00 P.M.-7:00 A.M. nurse and the nurse told them nothing had happened on her shift, (though her nurses note said otherwise). When asked if all applicable staff on the previous 2 shifts were interviewed, both the DON and Administrator said no. They said the Resident did tell the same story multiple times, including to the Social Worker days after the initial allegation. The Administrator said the staff interviews should have been written down, per facility policy.

2. For Resident #16 the facility staff failed to investigate two different occurrences for bruises of unknown etiology.

Resident #16 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. This Resident resided on the DSCU.

a. Review of the quarterly MDS, dated [DATE], indicated the Resident had severe cognitive impairment with a score of 0 out of 15 on the BIMS.

b. Review of a Nurses Progress Note, dated 2/5/16, indicated the Resident had a dark purple bruise to the left eye. Review of the POS [REDACTED]

-Review of Incident: bruise left eye, possibly caused by glasses, no recall of what happened and Resident denies anyone touched him/her.

-Immediate Intervention: Monitor -Interdisciplinary Team (IDT) Review: Bed o.k. Further review of the report did not indicate which staff were on duty for the previous shifts. Also, it did not indicate if any staff were interviewed, as there were no written statements provided by the facility upon the surveyor’s request. Review of Nurses Progress Note, dated 3/5/16, indicated the bruise to left eye resolved (one month later).

c. Review of the quarterly MDS assessment, dated 3/9/16, indicated the Resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 out of 15.

Review of the Nurses Progress Note, dated 3/25/16, indicated the Resident had bruising to forearms, was unable to explain etiology and denied abuse. Review of the POS [REDACTED]

-Review of Incident: hematomas (bruises) to forearms, denies pain

-Immediate Intervention: monitor site

-IDT Review: self propels in wheelchair, redirect as needed

Further review of the report did not indicate which staff were on duty for the previous shifts. Also, it did not indicate if any staff were interviewed, as there were no written statements provided by the facility upon the surveyor’s request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility staff failed to properly investigate an allegation of abuse for 1 Resident (#4) and failed to complete two investigations related to bruises of unknown etiology for 1 Resident (#16) out of a total sample of 24 residents.

Findings include:

Review of the facility Policy for Abuse and Prohibition, effective 4/10/03 and revised 2/28/17, indicated the following:

a. Purpose- The purpose is to protect the resident from verbal, sexual, physical, and mental abuse by anyone including but not limited to, staff, other residents, consultants or volunteers, staff from other agencies, family members or legal guardians, friends, or other individuals.

b. Physical abuse- includes hitting, slapping, pinching, kicking.

c. Identification- all incidents of unexplained or questionable injury such as bruising, will be investigated in order to identify potential abuse or mistreatment.

d. Investigation and Reporting- Anyone who witnesses .or has received a complaint of abuse from a resident or family member is required to report it immediately to the nursing supervisor.

-The nursing supervisor (or designee) will be responsible for completing an incident report and beginning an investigation.

-The Administrator or Director of Nurses (or designated individual) will conduct a thorough investigation of the allegation. The investigation will include interviews with victim, staff, residents, or anyone else involved with or having knowledge of the event.

-The investigation will be completed in written detail with signed individual statements from all individuals or interviewers.

Resident #4 was admitted to the facility in 10/2014 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 9/13/16, indicated the Resident had moderate cognitive deficits with a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Further review indicated he/she had no mood issues and his/her Health Care Proxy (HCP) was not invoked.

Review of the SBAR Progress Note, dated 12/4/16, indicated the Resident reported he/she had been punched in the stomach. The Resident complained of an upset stomach and then told the nurse,it started after that girl punched me in the stomach this morning. The Resident went on to say that he/she was half asleep when the girl came in and woke the Resident up by punching him/her in the stomach. The nurse wrote that the Resident repeated the story multiple times to multiple people. Further review indicated the nursing supervisor was contacted to initiate an investigation, and the Director of Nurses (DON) was also notified.

Review of a statement written by Nurse #4, dated 12/4/16, indicated that she was supervising the dining room that morning when the Resident requested crackers for an upset stomach that was caused by being punched in the stomach. Nurse #4 went to speak to the nurse who had worked the 11:00 P.M.- 7:00 A.M. shift and that nurse reported she was aware and had looked into it.

Review of the Progress Note, dated 12/6/16, indicated the DON met with the Resident on 12/5/16 and the Resident denied stomach pain. The Resident was able to give vague recall related to an incident over the previous weekend but was unclear to the exact details. Review of the Progress Note, dated 12/7/16, indicated the Social Worker met with the Resident on 12/6/16 with the family present. The Resident greeted the SW by saying I bet I know why you’re here then proceeded to tell the SW that someone punched him/her in the stomach. Family reported the Resident told them the same thing. Resident was unable to provide details of the allegation, family reported to SW that Resident had made similar allegation in the past but found no basis for the allegation. Further review of the note indicated the facility staff planned to have HCP invoked. Review of the Nurses Progress Note, dated 12/7/16 (11:00 P.M.-7:00 A.M.) indicated a nursing entry in response to SBAR submitted 12/4/16. Further review indicated the Resident had reported being punched in the stomach to the nurse, the Resident reportedly said he/she didn’t know if the person was a male or female. The nurse assessed the Resident for injury and found none. Further review indicated the nurse did not report the allegation to the nursing supervisor and did not initiate an investigation. The Resident did not report stomach pain/gastro intestinal upset at that time.

Review of the current care plan did not indicate the resident had a history of [REDACTED].

Review of the Incident/Accident report did not indicate which staff were on duty for the 11:00 P.M.-7:00 A.M. or the previous 3:00 P.M.-11:00 P.M. shifts. Also, it did not indicate which staff were interviewed, when they were interviewed, and what specifically was said as there were no written statements provided by the facility upon the surveyor’s request.

During an interview on 3/24/17, in the presence of another surveyor, the DON and Administrator both said they had talked to staff regarding the allegation of abuse made on 12/4/16. They said they talked to the 11:00 P.M.-7:00 A.M. nurse and the nurse told them nothing had happened on her shift, (though her nurses note said otherwise). When asked if all applicable staff on the previous 2 shifts were interviewed, both the DON and Administrator said no. They said the Resident did tell the same story multiple times, including to the Social Worker days after the initial allegation. The Administrator said the staff interviews should have been written down, per facility policy.

2. For Resident #16 the facility staff failed to investigate two different occurrences for bruises of unknown etiology. Resident #16 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. This Resident resided on the DSCU.

a. Review of the quarterly MDS, dated [DATE], indicated the Resident had severe cognitive impairment with a score of 0 out of 15 on the BIMS.

b. Review of a Nurses Progress Note, dated 2/5/16, indicated the Resident had a dark purple bruise to the left eye.

Review of the POS [REDACTED]

-Review of Incident: bruise left eye, possibly caused by glasses, no recall of what happened and Resident denies anyone touched him/her.

-Immediate Intervention: Monitor

-Interdisciplinary Team (IDT) Review: Bed o.k. Further review of the report did not indicate which staff were on duty for the previous shifts. Also, it did not indicate if any staff were interviewed, as there were no written statements provided by the facility upon the surveyor’s request. Review of Nurses Progress Note, dated 3/5/16, indicated the bruise to left eye resolved (one month later).

c. Review of the quarterly MDS assessment, dated 3/9/16, indicated the Resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 out of 15.

Review of the Nurses Progress Note, dated 3/25/16, indicated the Resident had bruising to forearms, was unable to explain etiology and denied abuse. Review of the POS [REDACTED]

-Review of Incident: hematomas (bruises) to forearms, denies pain

-Immediate Intervention: monitor site

-IDT Review: self propels in wheelchair, redirect as needed Further review of the report did not indicate which staff were on duty for the previous shifts.

Also, it did not indicate if any staff were interviewed, as there were no written statements provided by the facility upon the surveyor’s request. During an interview on 3/29/17 at 11:15 A.M., the DON gave the surveyor the Post Fall Incident Report forms and said she doesn’t use that form but the previous DON did. She said there should have been a full investigation done for both incidents of bruising and if they were done she was unable to locate them.

Based on observation and interview, the facility staff failed to promote dignity in dining when staff stood over residents while they assisted them to eat, for 2 residents (#1, #19) in a total sample of 24 residents and 3 non-sampled residents (NS#1, NS#2, NS#3).

Findings include:

On 03/23/17 from 9:12 A.M. through 9:40 A.M., during breakfast in the Fairbanks dining room, the Surveyor made the following observations:

1. Resident # 1 was fed by three different staff members, none of the staff were seated when they provided assistance. At 9:12 A.M., Res #1 was asleep at the dining room table. Nurse #1 woke the Resident and fed him/her a few bites of food, while standing, before leaving to do another task. The Nurse did not return and the Resident did not eat any food on his/her own. At 9:29 A.M., Certified Nursing Assistant (CNA) #2 stood next to the Resident and provided a few bites of breakfast, before she went to the steam table to serve. Nurse #1 returned and needed to wake the Resident to provide a few bites of food, while standing. CNA #1 fed the resident the remainder of breakfast, while standing over him/her.

2. NS #2 was fed by two different staff members, neither of the staff were seated when they provided assistance. At 9:15 A.M. the Surveyor observed CNA #1 feed 3 bites of applesauce to the Resident, before she left the dining room to answer a bed alarm down the hall. NS #2 fell asleep at the table until 9:40 A.M. CNA #2 woke the resident and fed him/her the remainder of breakfast, while standing. On 03/23/17 from 12:35 P.M. through 1:35 P.M., during lunch in the Fairbanks dining room, the Surveyor made the following observations:

1. CNA #3 fed a couple bites of salad to Resident #19, without sitting down, then walked away to get silverware for another resident. The CNA did not return and the Resident did not eat any food on his/her own. At 12:50 P.M., the Resident’s lunch was served but no one came to assist. At 1:00 P.M. CNA #3 put a cover over the Resident’s food. At 1:05 P.M. the CNA came over to feed the Resident.

2. CNA #1 fed salad to NS #3 while standing, followed by a glass of water. The CNA then filled a glass of milk for another resident before returning to feed NS #3. CNA # 1 fed the entire meal to the Resident while standing with only minimal verbal interaction.

3. CNA #1 attempted to feed NS #1 but he/she refused, so she left. At 1:25 P.M., CNA #1 stood to feed the resident a few bites of food, saw the surveyor and pulled a chair over to sit.

4. At 1:30 P.M. CNA #2 fed NS #2 a few bites of food and stood for the entire duration of the meal.

During an interview on 3/23/17 at 1:35 P.M., CNA #2 said they take turns feeding the residents. She said she stood to feed because there were no seats available. She said she put the lunch in front of NS #1 and Resident #19 because CNA #1 was supposed to feed them. She said there are four CNAs, so two pass the food and two help feed, but if residents get up the aides need to toilet them or provide care.

During an interview on 3/23/17 at 1:40 P.M. CNA#1 said she is per diem and she follows the schedule. She said she stood to feed NS #3 because the dining room was too crowded. She said she usually stands because she needs to get to the residents quickly before they stand up.

During an interview on 3/23/17 at 1:45 P.M. CNA #3 said she fed Res #19 only bites because she knew she wasn’t feeling well recently. She said she probably shouldn’t have fed her a few bites and then left to do another task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility staff failed to follow the written plan of care for 2 residents (#6 and #16) out of total sample of 24 residents.

Findings include:

1. For Resident # 6 the facility staff failed to obtain an apical pulse (pulse recorded from the heart) prior to the administration of [MEDICATION NAME] (a blood pressure medication) as ordered by the Physician. Resident #6 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the 1/2017 Medication Administration Record (MAR) indicated a physician’s orders [REDACTED]. Further review indicated the AP was not documented for 22 out of 28 administered doses. Review of the 2/2017 MAR indicated [MEDICATION NAME] 120 mg ER was administered 22 days. Further review indicated the AP was not documented for 14 out of 22 doses.

Review of the 3/2017 MAR indicated [MEDICATION NAME] 120 mg ER was administered 28 days. Further review indicated the AP was not documented for 17 out of 28 doses. During an interview on 3/28/17 at 10:45 A.M., Unit Manager (UM) #1 said the AP should have been documented on the MARs. He said the MAR was the only place the nurses documented the AP.

2. For Resident #16 the facility staff failed to provide protective padding to the bed siderail in accordance with the Resident’s care plan. Resident #16 was admitted to the facility in 3/2015 with [DIAGNOSES REDACTED]. Review of the care plan initiated 9/16/15, with goal date of 6/7/17, indicated the Resident was at risk for bleeding due to anticoagulation therapy in the form of [MEDICATION NAME] (blood thinning medication). Interventions included monitoring the Resident for bruises.

Further review indicated a care plan initiated 9/16/15, with goal date of 6/7/17, for risk of pressure ulcers. Interventions included a foam protector to the right side rail. During observation on 3/28/17 at 4:30 P.M., the surveyor observed the Resident’s bed to be unoccupied with bilateral unpadded siderails. During observation on 3/29/17 at 2:25 P.M., the surveyor observed the Resident’s bed to be unoccupied with bilateral unpadded siderails. During an interview on 3/29/17 at 2:30 P.M., Nurse #3 accompanied the surveyor to the Resident’s room. Nurse #3 said the siderails had always looked the way they did and there was no padding on either siderail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to provide a Physician ordered medication for 1 Resident (#8) out of a total sample of 24 residents.

Findings include:

Resident #8 was admitted to the facility in 12/2011 with [DIAGNOSES REDACTED]. Review of the care plan for mood state, initial date of 9/15/15 and goal date of 3/23/17, indicated the following:

-Problem: Resident #8 has a potential for alteration in mood status related to pseudobulbar affect diagnosis, also has had crying outbursts that are embarrassing to him/her caused by pseudobulbar affect.

-Goal: Resident will express feelings and concerns freely through the review dated and crying/laughing outbursts will lessen with use of Nuedexta.

-Intervention: Nuedexta as ordered. Nuedexta is used for the treatment of [REDACTED].

Review of the 3/2017 Medication Administration Record [REDACTED]. Further review indicated the medication was circled as not being given from 3/1/17 (9:00 P.M dose) thru 3/5/17, missing a total of 8 doses. Documentation on the backside of the MAR indicated [REDACTED].

During an interview on 3/24/17 at 11:45 A.M., Nurse #2 said the Nuedexta wasn’t available at the beginning of the month. She said she contacted the pharmacy to reorder since the medication wasn’t available in their central supply. During an interview on 3/24/17 at 12:45 P.M., Pharmacist #1 said the Nuedexta was unavailable because it needed a prior authorization (PA) from the insurance company. She said the PA is usually due annually but each insurance is different. Resident #8 has been on this medication since 9/2014.

Based on observation and interview the facility staff failed to properly date opened bottles of glucometer testing solution on 2 out of 3 units.

Findings include:

1. During tour of the Fairbanks medication room on 3/23/17 at 11:00 A.M., accompanied by Unit Manager (UM) # 2, the surveyor observed 2 undated open bottles of glucometer testing solutions. The solution is good for 90 days once opened. UM #2 said the bottles should have been dated when they were opened.

2. During tour of the Forbes medication room on 3/23/17 at 11:10 A.M., accompanied by UM #3, the surveyor observed 2 open bottles of glucometer testing solution inside of a box dated 2/14/17. The bottles were undated, allowing for the potential of being used erroneously if separated from the box.

UM #3 said the bottles, not the box, should have been dated when they were open to avoid potential error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility staff failed to maintain complete and accurate clinical records for 1 Resident (#6) out of a total sample of 24 residents.

Findings include:

For Resident # 6 the facility staff failed to document why a medication was not administered as ordered by the Physician. Resident #6 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the 2/2017 Medication Administration Record (MAR) indicated a physician’s orders [REDACTED].

Further review of the MAR indicated the medication was not signed off as being administered for 4 out of 28 days, the block for nurses to sign off was left blank on 2/7/17, 2/15/17, 2/22/17, and 2/23/17. Additionally, the nurses circled their initials indicating the medication was not administered for an additional 3 days- 2/14/17, 2/16/17, and 2/28/17. Further review of the MAR indicated no documentation to explain why the medication was held or not signed off for the above mentioned days. Review of the Progress Notes from 2/1/17-2/28/17 indicated no documentation to explain why the [MEDICATION NAME] was not administered as ordered. During an interview on 3/28/17 at 10:45 A.M., Unit Manager #1 said there were several blanks on the 2/2017 MAR and he didn’t know why the medication was circled as not being given on 2/14/17, 2/16/17 and 2/28/17. He said there should have been documentation in the nurses notes or MAR to explain why the medication wasn’t given as ordered.