ROYAL HEIGHTS NURSING & REHABILITATION CENTER
Facility I.D. Number 0041228
Date of Survey:05/07/02
Notice of Violation:08/09/02
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT.
A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR.
These regulations are not met as evidenced by:
Based on interview and record review, it was determined that the facility continued to employee a staff member (E9, Certified Nurse's Aide) after a witnessed incident of resident abuse. E9 was permitted to work in the facility as a security guard then again as a nurse's aide, until which time he abused a second resident.
On 4-24-02 the Department initiated investigation of a Hot Line complaint that physical abuse of a resident (R2) had been alleged against an employee (E9) within the facility.
During the interview of the Administrator (E1) the investigative report was made available.
On April 13, 2002 during patient care, R2 reported to E8 (CNA) that she had been abused by E9 (CNA). R2 stated that he (E9) had put a pillow over her head. E8 brought E9 into the room to question him in front of R2 and R2 became very agitated. R2 made a choking gesture and stated that E9 had choked her.
E9 reported to E8, "Hell yeh, so f---ing what." E9 then looked at R2 and told her to "shut up." E9 then left the room, (taken from written documentation of E8).
According to the administrator's statement, this information was not reported to administrative staff until April 17, 2002.
According to a telephone interview (4-26-02 at 3:44 p.m.) E8 states that she reported the abuse incident to E2 (Director of Nursing) within hours of the abuse.
On April 17, 2002, both E2 (Director of Nursing) and E15 (staff nurse) interviewed R2 concerning the abuse. R2 nodded her head, "yes" when questioned about E9 doing anything to her. She put her hands to her neck, making hand movements all over her body saying he touched her in those places and that he did it repeatedly everyday, (taken from written documentation of E15).
On 04-25-02 at 12:01 P.M. R2 stated, during an interview with surveyor, that E9 (called by his first name) had choked her and covered her face. As she spoke she moved her hands roughly over her face and head to describe his actions. R2 stated that E9 did this to her "all the time." R2 stated that he would also pull or hit on her arms and stomach. R2 stated that she had told E14 (charge nurse) but that she had done nothing. R2 became extremely agitated during this interview and needed to be calmed down in order to keep focused.
R2 has a history that includes: Parkinson's disease, Schizophrenia, bi-polar disorder, hypertension, osteoporosis and severe tardive dyskinesia. Her assessment of 4-12-02, indicates that she has no memory problems and is alert to person, place and time. R2's most recent care plan update is 4-30-02, which was after this surveyor entered the facility and noted no current care plan available. Her previous care plan was dated 9-7-01. She has had no social service assessments since 9-7-01. Neither nursing notes, nor Social Services notes, indicated the witnessed abuse to this resident. There is no record in her chart of the incident. R2 was observed to be alert to person and place at the time of the interview, (record review).
E9 has had a previous history of a resident abuse allegation while working in this facility. (The Department investigated this allegation on 12-14-01, and the facility was cited for failure to investigate resident abuse.)
During staff interviews on 4-25-02 it was determined that at least 3 nursing staff (E3, E4, E5) felt that the allegation of abuse of a resident (R3) on 12-14-02 was valid and that the resident witness (R4) was credible. E9 was permitted to work in a patient contact area as a security guard and then again as a nurse's aide, until 04-18-02.
On 5-03-02 at 9:15 A.M. while meeting with the Administrator (E1), she stated that she also believed that the Resident witnessing the 12-01 incident was credible and that she believed the allegation of abuse against E9 was valid at that time.
E9 was terminated from employment on 04-24-02 after the abuse committee concluded this investigation.
JKR:jlb/royal heights violation.wpd