BARNSVILLE, GA- HERITAGE INN OF BARNSVILLE HEALTH AND REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18639

Based on record review, resident and staff interviews, and review of the facility policy titled, Abuse
Prohibition, the facility failed to thoroughly investigate an allegation of abuse and to protect the resident during the investigation for one of four residents (R) (R#24) reviewed for allegations of abuse.

Findings included:
A review of the facility’s Abuse Prohibition policy, dated 2020, indicated the following in the section titled, Investigation and Follow Up:
After an allegation/incident has been reported to the state, incident should be investigated including but not limited to the following: Description of the event to include any identified injuries. Physical assessment of the patient may be required based on the nature of the allegation.

Additional excerpts from this section of the policy included, Interviews will be conducted of pertinent parties. Written statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative.

Information regarding the event will be gathered from the suspect, person making accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have credible, pertinent information. Identify and possible conflicts between witnesses.

This section further revealed, A follow up report detailing the findings of the investigation should be submitted to the Long Term Care Complaint Investigation unit within 5 business days. This may include but not [be] limited to:
– Details of the incident and injury if applicable.
– Summary of statements gathered from any witnesses or any other pertinent interviews conducted during the investigation.
– Action taken by center – safeguarding the patient(s) and preventing a reoccurrence. Any other police or ombudsman reports related to the investigation.
– For investigations when the alleged person is a CNA or a licensed staff person, additional information may be requested by the state agency or licensure/certification board.
– All investigative information will be kept on file in a secured location. All information gathered is confidential in nature.

In the section titled, Protection, the policy indicated, The following procedures will be followed to protect the patient from harm during the investigation:
– Center will respond immediately to protect the alleged victim and integrity of the investigation.
– Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.

– Increased supervision of the alleged victim and residents.
– During an active investigation of abuse, when there is substantial evidence that the abuse occurred, the suspected employee may be suspended without pay pending investigation. If allegations are unsubstantiated, the employee will be reimbursed for time lost.
– At the discretion of the Administrative staff, room or staffing changes may be implemented, if necessary, to protect the resident(s) from the alleged perpetrator.

A review of the Face Sheet for R#24 indicated diagnoses that included Parkinson’s disease.

Review of the quarterly Minimum Data Set, dated dated [DATE], revealed R#24 had a Brief Interview for Mental Status score of 15, which indicated R#24 was cognitively intact. The MDS indicated R#24 exhibited no indicators of psychosis, including delusions and/or hallucinations during the seven days prior to the assessment date. Per the MDS, R#24 required limited to  extensive assistance for most activities of daily living (ADLs) and was always incontinent of urine and bowel.

Review of the Care Plan for R#24 revealed no mention of a problem related to paranoid/delusional behavior until it was updated on 2/20/2023 following the inquiry by the surveyor. The update indicated R#24’s problems included behaviors (updated 2/20/2023) related to psychosocial factors (1/10/2023 onset), exhibiting paranoid/delusional behavior (2/13/2023 onset), continues to exhibit paranoid/delusional type behavior revolving around patient care (2/20/2023 onset), reliving closed events (2/20/2023 onset), and Parkinson’s delusions 02/20/2023 onset). Interventions included:
– Have two staff members in the resident’s room when providing ADL/incontinent care.
– Analyze key times, places, circumstances, triggers, and what de-escalates behavior.
– Be an active listener, allow for expression of feelings without censure.
– Continue to adjust staff as per resident request and as staffing allows.
– Follow reporting protocols.
– Follow-up with physician regarding ongoing verbalizations.

Review of a handwritten note, dated 2/13/2023, and written by the Assistant Director of Nursing (ADON), revealed R#24 reported that Certified Nursing Assistant (CNA) #8 took the draw sheet off R#24’s bed, twirled it around, then made it into a circle, taped the sheet over R#24’s rectum, then taped her vagina shut. R#24 then reported CNA #8 removed R#24’s clothing and left her on a cold exam table. There was no documentation to indicate that a thorough investigation was conducted/documented.

Interview on 2/20/2023 at 10:31 a.m. with R#24 revealed that on 2/11/2023 at about 9:25 a.m., she used her call light to get assistance because she thought she had been incontinent. R#24 stated CNA #8 came into the resident’s room and lowered the bed linen. Resident #24 stated CNA #8 instructed her to roll to her right side, removed R#24’s unsoiled adult brief, twisted a sheet, and placed it in R#24’s vaginal and rectal areas, taped it in a circular fashion, and left R#24 on their right side with their backside exposed for an hour. R#24 stated the incident was reported to the ADON on 2/13/2023. R#24 stated that after she told the ADON about the allegation, the ADON stated CNA #8 would not be allowed to provide care for the resident.

Interview on 2/20/2023 at 1:05 p.m. with the ADON, the ADON revealed that R#24 had delusions. The ADON stated R#24 reported the allegation regarding CNA #8 to her on 2/13/2023 and a thorough investigation was conducted in three to four hours and the alleged perpetrator, CNA #8, was removed from R#24’s care but not suspended. The only documentation of an investigation provided by the ADON was the handwritten note dated 2/13/2023 describing the allegation. There was no evidence that staff and residents were interviewed, and no evidence witness statements were obtained.

On 2/22/2023 at 2:04 p.m., the Director of Nursing (DON) provided documentation indicating that CNA #8 worked 12-hour shifts on 2/13/2023, 2/16/2023, 2/17/2023, and 2/21/2023. CNA #8 did not provide care for R#24; however, CNA #8 provided care for other residents on the hall where R#24 resided and delivered and retrieved meal trays from R#24’s room.

Interview on 2/23/2023 at 8:11 a.m. with the DON, she stated a thorough investigation had not been completed because, We did not move in the direction of abuse because we didn’t consider it abuse. The DON stated that the alleged perpetrator, CNA #8, was allowed to provide care to residents without a thorough investigation of the allegation of abuse being completed.

Interview on 2/23/2023 at 8:26 a.m. with the Administrator, they revealed that a thorough investigation had not been conducted because they did not consider the allegations to be abuse. The Administrator stated CNA #8 was allowed to continue to provide care to residents because they believed R#24 had a clinical situation, not valid abuse allegations. When asked if the facility’s Abuse Prohibition policy had been followed to conduct a thorough investigation, and/or to protect residents from the alleged perpetrator pending outcome of a thorough investigation, the Administrator stated, We are following it now. In hindsight, we would have done things differently.