GREENVILLE, SC- POINSETT REHABILITATION AND HEALTHCARE CENTER

Based on review of facility policy, record review, and interviews, the facility failed to ensure 1 Resident (R)59 of 8 residents reviewed for abuse was free from abuse. This deficient practice resulted in physical harm to R59 when R274 entered R59’s room, while the resident was in bed, and punched her in the face. R59 sustained fractures of the zygomatic arch (cheekbone) and orbital area (eye socket).

Findings include:
Review of the facility policy titled Abuse a Neglect – Clinical Protocol, dated 03/18 indicated .Residents have the right to be free from abuse, neglect. misappropriation of resident property and exploitation. This includes but is not limited to freedom from.physical abuse.Protect residents from abuse. neglect. exploitation or misappropriation of property by anyone including, but not necessarily limited to .other residents.
1. Review of R59’s electronic medical record (EMR) titled Admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]
Review of R59’s quarterly Minimum Data Set (MDS) in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/26/22 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which revealed the resident was severely cognitively impaired. This assessment revealed the resident was ambulatory and had no behaviors, such as physical aggression towards others during this assessment period.
Review of R59’s EMR Care Plan located under the Care Plan tab indicated the resident had cognitive impairment due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]
2. Review of R274’s EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Review of R274’s admission MDS with an ARD of 07/19/22 indicated the resident had a BIMS score of 1 out of 15, which revealed the resident was severely cognitively impaired.
Review of R274’s EMR Care Plan, located under the Care Plan tab dated 07/25/22 indicated the resident had cognitive impairment related to Alzheimer’s disease. The care plan revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was to not permit the resident from wandering and no more than one altercation of a resident-to-resident by the next care plan review.

Review of documents provided by the facility, referred to as the facility’s investigation, revealed on 08/18/22, a Certified Nursing Assistant (CNA) heard yelling and went to R59’s room and found R274 next to R59’s bed. CNA overheard R59 saying don’t hit me. The CNA was able to redirect R274 back to his room. The police were notified. The residents’ representatives were notified. The medical provider was notified and ordered R274 to be sent to the emergency room for evaluation and treatment. R274 did not return to the facility. R59 was sent to the hospital for evaluation and treatment. The facility investigation revealed R59 was returned back to the facility after being identified with facial injuries.

Review of documents provided by the facility titled CT [computed tomography] Head without Contrast dated 08/18/22 indicated the resident was punched in the face and as a result the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also sustained a left medial blowout fracture of the orbital wall.

During an interview on 10/12/22 at 1:06 PM, the Director of Social Services (DSS) stated she defined abuse as anything that was perceived as unwanted. The DSS stated there were no prior issues with R274 while he was living at the facility.

During an interview on 10/13/22 at 10:30 AM, the Administrator confirmed the resident-to-resident with R274 and R59 was abuse. The Administrator stated R274 was not brought back to the facility since he was a danger to himself and to others.
This deficiency was cited based on complaint intake #SC 806 and SC 80.