BARDSTOWN, KY – SIGNATURE HEALTHCARE AT COLONIAL REHAB & WELLNESS

Based on interview, record review, facility policy review, and facility investigation review it was determined that the facility failed to report an allegation of abuse within two (2) hours for one (1) of three (3) sampled residents (Resident #1). On 05/10/19, a facility hospitality aide allegedly observed State Registered Nurse Aide (SRNA) #2 smack Resident #1 on the lips while assisting the resident with a shower. However, the hospitality aide did not report the allegation to facility Administration until three (3) days later, on 05/13/19.

The findings include:
Review of facility policy titled Abuse, Neglect, and Misappropriation of Property, undated, revealed all alleged violations involving abuse, neglect, exploitation, or mistreatment are to be reported immediately, but no later than two hours after the allegation is made.

Review of Resident #1’s medical record revealed the facility admitted the resident on 12/01/15 with [DIAGNOSES REDACTED].

Review of Resident #1’s Quarterly Minimum Data Set (MDS) assessment, dated 04/10/19, revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the assessment. Review of the facility’s final investigation dated 05/17/19 revealed Hospitality Aide #1 was in the bathroom on 05/10/19 assisting SRNA #2 with giving Resident #1 a shower when she observed SRNA #2 smack Resident #1 on the lips.

Interview with Hospitality Aide #1 on 05/19/19 at 1:20 PM revealed on 05/10/19 she had observed SRNA #2 hit Resident #1 on the mouth while she was assisting the resident with a shower. Further interview with Hospitality Aide #1 revealed she had been trained to report any allegations of abuse to facility Administration immediately. Hospitality Aide #1 reported that she procrastinated in reporting the allegation because she was concerned about retaliation from SRNA #2.

Interview with the facility Director of Nursing (DON) on 05/19/19 at 1:35 PM revealed staff were trained upon hire and at least monthly thereafter to report any allegation of abuse immediately to facility Administration.

Continued interview with the DON revealed it was not acceptable to wait three (3) days to report an allegation of abuse.

Interview with the facility Administrator on 05/19/19 at 1:56 PM revealed all facility staff were trained to report any allegations of abuse immediately. Continued interview with the Administrator revealed Hospitality Aide #1 should have immediately reported the allegation involving SRNA #2 and Resident #1 that occurred on 05/10/19.