BROWNSVILLE, KY – EDMONSON CENTER

Based on interview, record review and review of the facility’s Policy, it was determined the facility failed to ensure its abuse policies were implemented for one (1) of eighteen (18) sampled residents (Residents #54).

State Registered Nurse Aide (SRNA) #2 alleged she witnessed SRNA #1 putting her hand against Resident #54’s mouth and nose pushing down, while stating, Do not [***] ing spit on me again, on 01/12/2020 at approximately 1:15 PM. However, SRNA #2 failed to immediately notify the Charge Nurse or administrative staff of what she had witnessed as per facility Policy. SRNA #2 did inform SRNA #3 of what she had witnessed, and SRNA #3 informed SRNA #4 of the allegation. SRNA #4 then reported the allegation to Licensed Practical Nurse (LPN) #1 on 01/12/2020 at approximately 2:20 PM. LPN #1 notified the Assistant Director of Nursing (ADON) via telephone on 01/12/2020 at approximately 2:53 PM. However, there was no documented evidence the facility Policy was implemented related to reporting the allegation to State Agencies within the two (2) hour timeframe, conducting a thorough investigation or protecting residents from abuse pending an investigation. The allegation was not reported to the State Agencies until 01/15/2020, when the allegation was further investigated, three (3) days after the alleged abuse was witnessed. Additionally, the alleged perpetrator, SRNA #1, continued to work on 01/12/2020 and 01/13/2020, providing direct care, allowing for the potential for further abuse. (Refer to F-609 and F-610)

The facility’s failure to implement its policies and procedures regarding reporting, and investigating allegations of abuse, and protecting residents after an allegation of abuse, has caused or is likely to cause serious injury, serious harm, serious impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 03/04/2020, and was determined to exist on 01/12/2020.

The facility provided an acceptable credible Allegation of Compliance (AoC)/IJ Removal Plan on 03/06/2020, alleging removal of the Immediate Jeopardy on 01/18/2020. The State Survey Agency (SSA) determined the Immediate Jeopardy had been removed 01/18/2020, as alleged. In addition, the SSA validated the facility had implemented corrective action with a compliance date of 02/20/2020, prior to the SSA entering the building on 03/02/2020. Therefore, the SSA determined the facility had past-noncompliance.

Further review of the facility’s Investigation, revealed on 01/14/2020, SRNA #2 notified the CED of a different version of the situation related to Resident #54, which included profane language and possible physical abuse. SRNA #2 was instructed to come to the facility for further interview and to give a written Statement. Per the Investigation, SRNA #2’s Written Statement obtained on 01/15/2020, was inconsistent with the Verbal Statement obtained on 01/12/2020. Further the Investigation revealed on 01/15/2020, SRNA #2 alleged that on 01/12/2020, SRNA #1 said to Resident #54, Do not [***] ing spit on me again. SRNA #2 further alleged SRNA #1 put her hands on the resident’s mouth and nose and it looked like she pushed onto the resident’s face.

Continued review of the Investigation, revealed on 01/15/2020, when the ADON and the CED determined this was an allegation of abuse, the alleged perpetrator, SRNA #1, was suspended, which was three (3) days after the alleged incident was witnessed. SRNA #2 was also suspended on 01/15/2020 for not immediately reporting the allegation of abuse to her direct supervisor on 01/12/2020. The facility reported the allegation to Adult Protective Services (APS) and the Ombudsman on 01/15/2020 at 3:00 PM; the Office of Inspector General (OIG/ the SSA) on 01/15/2020, at 3:49 PM; and Resident #54’s Physician and Son on 01/15/2020 at 4:00 PM. The State Agencies were notified of the allegation, three (3) days after the alleged incident was witnessed.