CARTERSVILLE, GA- TOWNSEND PARK HEALTH AND REHABILITATION

Based on staff interview, record review, and review of facility policy titled, Abuse Prohibition, the facility failed to ensure residents were free from physical abuse by another resident for one of one resident (R) 35 reviewed for resident-to-resident altercations and one supplemental resident R57. R35 was the victim of physical abuse perpetrated by R33 on three occasions and R57 was the victim of physical abuse perpetrated by R33 on one occasion. This deficient practice had the potential to affect the safety of all residents in the facility.

Findings include:

Review of the facility’s policy titled, Abuse Prohibition, revised December 2022, revealed . It is the intent of this center to actively preserve each patient’s right to be free from mistreatment, neglect, abuse .This policy applies to anyone subjecting a patient to abuse including center staff, other patients .The center will identify, correct, and intervene in situations in which abuse .is more likely to occur. This will include an analysis of: The deployment of staff on each shift in sufficient numbers to meet the needs of the patients and assure that the staff assigned has knowledge of the individual patients’ care needs. The assessment, care planning and monitoring of patients with specialty needs and behaviors which might lead to conflict, such as patients with a history of aggressive behaviors, patients who have behaviors such as entering other patients’ room .
Protect the residents from abuse by anyone including, but necessarily limited to: Facility staff, other residents .Patients who have displayed or attempted to display abusive behavior towards other patients. ii. From the assessment, intervention strategies will be developed on the care plan or behavior management plan to prevent occurrences including monitoring for factors that trigger abusive behavior for this patient iii. The care plan including interventions will be evaluated on a regular basis and revised as necessary. Allegations that do not involve abuse or allegations with serious bodily injury must be reported immediately but no later than 24 hours . At the discretion of the Administrative staff, room changes may be implemented, if necessary, to protect the resident(s) from the alleged perpetrator.

1. Review of R35’s Face Sheet from the electronic medical record (EMR) Data Collection; Admission Data tab showed medical diagnoses that included Alzheimer’s disease with late onset, dementia with other behavioral disturbances; delusional disorder; and insomnia.

Review of R35’s quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 1/14/2023 showed a Brief Interview for Mental Status (BIMS) score of 99 indicative that the BIMS was not completed. The staff assessment for mental status indicated R35 had short and long term memory problems and was severely cognitively impaired in daily decision making.

Review of R35’s EMR Nurses Notes revealed: 4/09/2023 23:58 [11:58 p.m.]
Note Text: 19:15 p.m. [7:15 p.m.] Res [resident] [R35] was hit in the head and face per another resident [R33] with a small stuffed animal, no injuries were noted after assessing res [R35] but she is very anxious, the other res [R33] was separated from this resident [R35] and redirected to another area, this res [R35] was given prn [as needed] Ativan for anxiety.

4/18/2023 06:00 [6:00 a.m.] Note Text: Observation Data: Reason for observation: Follow-up Incident/Fall – Pushed against the door by another res. Pain location: Rt [right] Shoulder and Back

Additional comments: This res [R35] was constantly following the res [R33] that pushed her causing the other res to become agitated at her pushing her against the door frame stating [R33 cursed R35] this res [R35] hit her right shoulder and back during the incident, this nurse escorted this res [R35] back to her room away from the res [R33], when assessed no injuries were noted at the time.

4/24/2023 06:37 [6:37 a.m.] Note Text: While coming around the corner into the nurse’s station, this nurse obs [observed] another res [R33] slap this res [R35] on the left side of her face, I immediately went and separated the other res [R33] from this res [R35]. When I asked [R33] ‘Why did you slap her?’ She stated, ‘I’m having a bad day.’ A staff member assisted the other res [R35] to her room after I administered her meds, this res [R35] became a little anxious, mild redness noted to the left side of her face, res [R35] was given her meds and assisted to bed per staff.

Review of R35’s Care Plan from the EMR Care Plan tab showed:
Care Area/Problem: Altercations/risk of altercation (4/09/2023: Onset). Goal: Patient will not injure self or others during the review period (4/09/2023: Onset) Interventions: Administer medications as ordered, encourage patient to express feelings, intervene as needed, Notify MD [medical doctor] as indicated, observe patient to patient interactions

Review of the paper facility reported incident investigation, provided by the Administrator, included both the events on 4/09/2023 and 4/18/2023 (the investigation of the events of 4/23/2023 were still ongoing) showed the resident-to-resident abuse was unsubstantiated we were unable to substantiate abuse due to the cognition and intent of R33 during a paranoid state. The MD and responsible parties agree with the plan. Both residents will continue to be followed. An abuse in-service with associates was held today.

During an interview on 4/25/23 at 4:44 p.m., regarding the incidents with R33, the charge nurse Licensed Practical Nurse (LPN) 2 stated, There was an incident last week with [R33] and [R35] during which [R35] was sitting and [R33] had a stuffed animal in her hand. LPN2 stated it occurred on the night shift and the interventions at that time were that they separated them. LPN2 stated that yesterday (4/24/2023) there was another incident, R33 came and slapped R35. LPN2 stated the staff intervened and separated them. LPN2 stated that at one point they were doing one on one with R33, but that there is always a nurse aide on the unit. There is one nurse aide on the unit for the twelve residents.

2. Review of R57’s Face Sheet from the EMR Data Collection; Admission Data tab showed diagnoses including Alzheimer’s disease with late onset; dementia in other diseases classified elsewhere, moderate, without other behavioral disturbances; generalized anxiety disorder; and depression.

Review of R57’s admission MDS, with an ARD of 3/02/2023 showed a BIMS score of six out of 15, indicative that the resident was severely cognitively impaired in daily decision making.

Review of R33’s EMR Nurses Notes revealed:
4/23/2023 19:00 [09:00 p.m.] This nurse witnessed Resident [R33] wandering in hallway of secured unit, raise hand up in air then hit another resident [R57] on right upper arm causing redness immediately afterwards.

During an interview on 4/25/2023 at 6:00 p.m. with the Administrator and the Director of Nursing (DON) it was revealed that R33 had a history of behaviors and that was why she was placed on Seroquel (an antipsychotic medication) originally. The physician did a Gradual Dose Reduction (GDR) with Seroquel, and it was discontinued in February 2023. They noticed the behaviors starting again. The first incident was 4/09/2023, R33 hit R35 with a stuffed animal. The DON revealed that R35 gets on R33’s nerves, and R35 did turn around and hit R33 in the face. The DON stated staff redirected R33 and put her in an area where she could be visualized by the staff. The DON continued to state, on 4/17/2023, R33 shoved R35 into the bathroom door and there were no injuries; afterwards, both residents were put to bed, and a urinalysis was ordered for R33. Depakote was ordered for R33, and increased observations were provided by staff. The
Administrator stated that an Administrative Assistant provided close observation of R33 from 1:00 p.m. to 2:45 p.m. on 4/18/2023 by sitting outside of her room in a chair. On 4/23/2023, R33 hit a different resident, R57, in the arm in the common area on the memory care unit. No injuries were noted. Interventions included separating the residents and increasing observations by the nursing staff. On 4/24/2023, R33 was sent to the emergency room (ER) where the psychiatrist made the recommendation to restart the antipsychotic medication. The Administrator indicated R33 was sent to the ER because the close supervision was not working. The Administrator stated she sent referrals to other facilities for placement of R33. The Administrator stated she considered moving R33 and R35 off the memory care unit, but they wander so they cannot be removed from the locked unit. The Administrator indicated she provided abuse education to all staff on 4/17/2023 and 4/18/2023. The Administrator stated the policy said to report it and intervene, notify the physician; it says they will make sure they are free from abuse.

During an interview on 4/26/2023 at 5:31 a.m., Certified Nursing Assistant (CNA) 2 stated that R35 usually slept all night. CNA2 stated sometimes R33 wandered at night, sometimes into other residents’ rooms and takes things. CNA2 stated she was told to keep an eye on her [R33]. Sometimes she sees R33 wandering in the hallway when she comes out of her room and watches her. When they go on break, another nurse covers the watching of residents. Often a CNA from another unit will come over. This evening R33 had a sitter.

During an interview on 4/26/2023 at 5:38 a.m., the Environmental Services Aide stated she helped in other areas, though she was not a CNA. The Environmental Services Aide stated the first time she sat with R33 she was told to watch the resident and that if she got up to stick close to her. The Environmental Services aide stated she was not told that R33 had hit, shoved, or threw anything at anyone, but heard she was told keep an eye on R33 if she woke up and stay close to her and not let her go into other rooms.

During an interview on 4/26/2023 at 5:56 a.m., LPN1, a staff nurse that covers both halls, stated that in the incident last week, R33 pushed R35 into the door frame, and called her a bitch, there was no injury. LPN1 stated the second incident occurred in hallway tv area next to nurses’ station, R33 came around the corner and just walked up and slapped R35, R35 had a red area on the face. LPN1 stated around 6:40 a.m. that day the staff were told to watch R33, it was not a one on one though. LPN1 stated they were not able to provide close supervision, because there was only one CNA on each side and one nurse. Often a nurse is in a room and CNAs are in rooms and sometimes there was only one CNA for both units. LPN1 stated since the first incident, there had been only one CNA and since the second incident only one CNA. LPN1 stated on Sunday (4/23/2023), R33 hit another resident, R57, before she had slapped R35 and the incidents were reported to management. LPN1 stated the staff were told to watch, no additional staff were added. LPN1
stated other residents on the floor may not be safe without one-on-one supervision until R33’s meds are adjusted.

During an interview on 4/26/2023 at 7:26 a.m., the Administrator stated that for today R33 has had a one on one, they added one at 6:45 p.m. last night the day she hit R57. The Administrator stated, Things progressed and the doctor agreed to send her out [to the ER]. This was not her normal. We didn’t expect that this would happen. At some point you run out of interventions.