REISTERSTOWN, MD – FUTURE CARE CHERRYWOOD

Based on review of medical records and other pertinent documentation and interviews it was determined that the facility failed to ensure that staff immediately reported observations of suspected abuse to the Administrator as evidenced by abuse being observed on three separate occasions by three different staff members prior to it being reported to the Administrator; failed to ensure supervisory staff reported abuse allegations to the Administrator within 2 hours after the allegation was made as evidenced by nursing supervisor waiting more than 8 hours before reporting the allegation to a Unit Nurse Manager (Resident #41); and failed to report allegations of abuse to the state survey agency (Resident #6). This was found to be evident for 2 out of the 38 residents reviewed during the survey.

On 1/18/19 at 3:58 PM Nursing supervisor #14 was interviewed. She reported that GNA #4 had reported the abuse concerns to her towards the end of the evening shift of 12/27/18. Nurse #14 also reported that she had done a physical assessment of the resident. When asked where the assessment was documented Nurse #14 responded: nurses do documentation every shift and if you check the notes there should be a note from the nurse.

Review of the medical record revealed a nursing note, dated 12/27/18 at 10:47 PM written by Nurse #31 which addressed basic care and medical status during the shift. Further review of the nursing notes failed to reveal documentation of an assessment during the 12/27/18 night shift or any shift on 12/28/18.

A Late Entry for 12/28/18 was found, written by ADON #13, which referenced the GNAs observation of a (male/female) sitting in a chair beside the bed with (his/her) arms extended and both hands on resident’s chest. This note included that the health care practitioner and responsible party were made aware but failed to include any information in regards to an assessment of the resident.

Review of the medical record failed to reveal any documentation of a physical assessment of the resident by Nurse #14 on 12/27/18 or 12/28/18. The resident was not seen by a primary care provider until 1/10/19.

On 1/24/19 at 10:00 AM when asked about expectations of an assessment after an allegation of abuse the Medical Director reported that he would expect a thorough assessment by nursing, then if any concerns a follow up with the doctor. Surveyor then reviewed the concern with the Medical Director, the Director of Nursing (DON) and corporate nurse that there was no documentation found in the medical record of an assessment of the resident following the abuse report.