PHOENIX, AZ – DESERT PEAK CARE CENTER

Based on clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure that allegations of resident to resident abuse were reported to the State agency within the required 2-hour timeframe for three incidents involving residents (#49 & #180, #93 & #56, and #82 & #229). The deficient practice could result in allegations of abuse not being reported timely.

According to the facility’s self-report document, on October 6, 2022 resident #180 was wheeling down the hall and resident #49 came out of the room and they met together. Resident #180 became aggressive by yelling, screaming, cursing. According to the report, while staff was attempting to intervene, the residents had contact by holding onto shirts by the arm area and pulling. The report stated the date of the event was October 6, 2022 and the time of the event was 8:00 AM. The report stated that the camera footage was confirmed with the time of events and report from staff. The report stated that the alleged perpetrator of the incident was resident #180. The report stated that the incident was notified to the State agency.

According to the facility’s self-report document, on September 7, 2022 resident #56 was witnessed pushing resident #93 by placing her hands onto the arm/chest area of resident #93. The report stated the date of the event was September 7, 2022 and the time of the event was 8:00 AM. The report stated that the alleged perpetrator of the incident was resident #56.

A Health Status Note dated October 2, 2022 at 2:15 PM stated the nursing staff received in a report that overnight resident #82 got out of bed and removed the roommate, resident #229’s blankets. Resident #229 was uncomfortable with resident #82 at his bedside at night. Resident #82 was interviewed and had no recollection of anything that had happened. Resident #82 was moved to a different room.

An interview was conducted with a Licensed Practical Nurse (LPN/staff #201) on October 27, 2022 at 11:07 AM. She stated when there is an incident where a resident hits another resident, the process is to make sure the residents are separated, make sure they are safe and report to state agency, police, APS, etc. She stated there is a 2-hour window to report the incidents.

An interview was conducted with the facility’s administrator (staff #3) on October 27, 2022 at 1:59 PM. She stated that each nursing station has a red binder which includes a packet that list step by step on what to do when there is resident to resident altercations. She stated the list included a link to report the incident to DHS (Department of Health) and APS. The list also included the phone number for the ombudsman and phoenix police. She stated the incident of abuse should be reported within 2 hour and the staff should be reporting the incident immediately.