LOUISVILLE, KY – SIGNATURE HEALTHCARE AT JEFFERSON PLACE

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

Based on interview, record review, and review of the facility’s policy, investigations, and Complaint/Grievance Reports, it was determined the facility failed to have an effective system to ensure residents were free from abuse and neglect for four (4) of ten (10) sampled residents, Residents #1, #2, #4, and #5.

Interview with Resident #4’s Granddaughter (GD) revealed on 10/12/18 at approximately 10:30 PM, her grandparent called and reported to her State Registered Nurse Aide (SRNA) #3 took off his/her back brace and slung it across the room, told the resident to get himself/herself off the toilet and to bed by himself/herself, and refused to assist the resident with incontinent care by telling the resident he/she was clean enough, then left the room. In addition, Resident #4 told her the night before the same SRNA gave him/her a shower in hot water and when the resident told SRNA #3 the water was too hot, the SRNA continued to give him/her the shower. Resident #4’s GD stated she immediately phoned the facility because she felt SRNA #3 was abusive to Resident #4 and reported the incidents to the night shift House Supervisor, Licensed Practical Nurse (LPN) #4, and also completed grievances with the facility the next day. Interview with LPN #4 revealed she received the report from Resident #4’s GD but did not report the incident to the Administrator or the Director of Nursing (DON), per the facility’s policy and procedures, because she thought Resident #4 might have been confused and considered the resident’s concern as a grievance.

Review of the facility’s Complaint Grievance Report, completed 08/31/18, revealed under Investigation Findings, Resident #5 stated he/she needed assistance with a brief change and an unknown staff member responded to Resident #5’s call light. The staff member advised the resident an extra-large brief was the only size and he/she would have to use it. The resident stated he/she requested a smaller size and the staff member told him/her that was the only size. Resident #5 stated the staff member told him/her in fact just do it yourself and left the room. Resident #5 fell while trying to put the brief on without assistance and sustained a skin tear. Resident #5 reported the incident to LPN #5; however, LPN #5 treated the information as a grievance and did not report the allegation that an employee failed to provide services to the DON or the Administrator, per the facility’s policy and procedure.

Review of a facility Investigative Summary, not dated, revealed on 07/22/18 at approximately 10:30 PM, Resident #1 rang his/her call light for assistance. SRNA #1 entered Resident #1’s room and stated, What do you want? Resident #1 stated he/she needed his/her bed adjusted so he/she could use his/her urinal. SRNA #1 stated to Resident #1, I’m not messing with you, solve it yourself in a loud and angry tone of voice and then left the room.

Interview with LPN #3 revealed Resident #2 reported to her on 07/20/18, that SRNA #2 cursed him/her, was rude, and had a bad attitude. LPN #3 stated she told SRNA #2 not to go back into Resident #2’s room for the rest of the evening. LPN #3 stated she did not view the incident as an allegation of verbal abuse.

The facility’s failure to ensure residents were free from abuse/neglect has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/07/18 and was determined to exist on 07/20/18. The facility was notified of the Immediate Jeopardy on 11/07/18.