Baptist Nursing Home-calhoun, Inc

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from sexual abuse, resulting in a serious incident involving two residents on the Special Care Unit. One resident with a history of severe cognitive impairment and Alzheimer's Disease was found in her bed with another resident on top of her, his hand inside her incontinence brief, performing jabbing motions. Staff observed scratches, bruising, and edema on the resident's labia and thigh, as well as bruising to her eyebrow. The incident was witnessed by multiple CNAs and a nurse, who reported that the male resident became violent and struck a staff member when they attempted to intervene. Prior to this event, the male resident had a documented history of sexually inappropriate behaviors, including making explicit comments, grabbing staff, and attempting to touch staff inappropriately. These behaviors had been ongoing since at least November of the previous year, with multiple entries in his medical record noting sexual comments and physical actions toward staff. Despite these documented behaviors, the facility did not implement effective interventions to prevent further sexual behaviors or protect other residents from potential harm. Staff interviews confirmed that the male resident frequently made sexual statements and gestures toward both staff and other residents, and had previously grabbed staff inappropriately. On the day of the incident, he was able to access another resident's room and commit sexual abuse, indicating a lack of adequate supervision and preventive measures. The facility did not assess other residents for signs of abuse immediately following the incident, and no body audits were performed on other residents at that time. The failure to address the ongoing sexually inappropriate behaviors and to implement sufficient interventions led to an incident that caused and was likely to cause serious harm.

Removal Plan

• Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
• Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
• A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
• LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
• Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings included red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of a quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
• Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
• NHA notified the Ombudsman of the incident.
• LMSW notified Resident #56's Responsible Party (RP) of the incident.
• NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event. to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident # 16 and continuing supervision.
• RP of Resident # 16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
• LMSW verified that a CNA was placed outside Resident #16's room.
• NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
• A follow-up weekly body audit completed on Resident # 56. No additional injuries identified.
• Primary physician notified of Resident # 16 acceptance at behavioral health facility.
• NHA notified the Attorney General's Office of the incident.
• NHA sent an email reporting the incident to the MSDH via email to [email protected].
• Resident # 16 was transferred to a behavioral health facility.
• NHA notified local law enforcement of the incident.
• Local law enforcement on-site.
• Incident report received from local law enforcement.
• The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
• The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
• The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
• No staff, including the Director of Nursing, will be allowed to work until in serviced.
• An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
• A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
• The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an alleged incident of sexual abuse within the required two-hour timeframe to the appropriate authorities. The incident involved a resident who was found by a CNA on top of another resident in bed, with his hand inside her incontinence brief, performing jabbing motions. Both residents were clothed at the time, but the CNA observed the inappropriate behavior and called for assistance. The male resident became violent when staff attempted to remove him, striking a staff member in the process. Upon assessment, the female resident was found to have scratches and bruising on her upper legs and labia, as well as additional bruising and discoloration on her thigh and eyebrow. Facility records show that the incident was reported internally to the nursing home administrator and social worker shortly after it occurred. However, the administrator did not recognize the event as sexual abuse and did not report it to the State Department within the required two-hour window. Instead, the administrator believed there was a 24-hour reporting window and notified the State Department the following day. The incident was also not reported to local law enforcement immediately, as the administrator did not initially view it as a crime. The facility's policy, in accordance with the Elder Justice Act, requires that any suspicion of a crime involving serious bodily injury to a resident be reported immediately, but no later than two hours after the suspicion arises. The failure to report the incident in a timely manner placed the affected resident and others at risk for further harm. The survey agency identified this as Immediate Jeopardy and Substandard Quality of Care, citing the facility for not adhering to regulatory requirements for reporting alleged violations.

Removal Plan

• Certified Nursing Assistant (CNA) 1 saw Resident #16 on top of Resident #56. CNA 1 yelled for help. Licensed Practical Nurse (LPN) 1 and CNA 1, CNA 2, and CNA 3 entered the room and removed Resident #16 and took him back to his room where supervision was provided by CNA 2.
• Licensed Master Social Worker (LMSW) and Nursing Home Administrator (NHA) notified by LPN of the incident.
• A CNA was stationed outside the door of Resident #16 until transportation arrived to take him to an inpatient geropsychiatric unit.
• LMSW went to evaluate Resident #16 for mood or behavior changes, and none were noted.
• Staff Development Specialist (SDS) performed a full body audit on Resident #56. The findings were red purple bruising with yellow edges noted to left outer eyebrow, scratches, skin discoloration and slight edema noted to exterior labia overall paleness maroon/purple bruising noted to left thigh approximate size of quarter scratches noted to left thigh and bilateral outer labia with bruising and redness noted to both areas.
• Nursing Home Medical Staff Director (NHMSD) notified by phone by RN 1 of findings from body audit. No orders received.
• NHA notified the Ombudsman of the incident.
• LMSW notified the Responsible Party (RP) of the incident.
• NHA and Risk Manager (RM) notified the Director of Risk Management (DRM) of the event to discuss the event and necessary actions steps needed to be implemented immediately to prevent any further harm. The recommended actions included continuing to seek inpatient geropsychiatric unit placement for Resident #16 and continuing supervision.
• RP of Resident #16 was notified by LMSW regarding the incident and an order for inpatient geriatric psych placement.
• LMSW verified that a CNA was placed outside Resident #16's room.
• NHA notified the Mississippi State Department of Health (MSDH) of the incident by telephone.
• A follow-up weekly body audit completed on Resident #56. No additional injuries identified.
• Primary physician notified of Resident #16 acceptance at behavioral health facility.
• NHA notified the Attorney General's Office of the incident.
• NHA sent an email reporting the incident to the MSDH via email to [email protected].
• Resident #16 was transferred to a behavioral health facility.
• NHA notified local law enforcement of the incident.
• Local law enforcement on-site.
• Incident report received from local law enforcement.
• The Director of Risk Management in-serviced the NHA and the Interim Director of Nursing (IDON) on timely reporting of suspected abuse.
• The Interim Director of Nursing and SDS initiated Abuse training to include types of abuse, prevention and employee responsibilities for reporting suspected abuse for all 129 employees. No staff will be allowed to work until in serviced.
• The IDON and SDS initiated an in-service for all Nursing Staff on implementing and developing Comprehensive Care Plans to include interventions that address inappropriate sexual behaviors. No staff will be allowed to work until in serviced.
• No staff, including the Director of Nursing, will be allowed to work until they are in-serviced.
• An Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, interim-Director of Nursing (DON), Infection Control Nurse Manager (ICNM), and RM.
• A Follow-up Ad hoc Quality Assurance (QA) meeting was held to review the immediate jeopardy related to F 600 Free from Abuse and Neglect, F 609 Reporting of Alleged Violations, and F 656 Develop/Implement Comprehensive Care Plan and conducted a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the NHA, NHMSD, DON, ICNM, RM, Human Resources Manager (HRM), and RN 1.
• The Minimum Data Set Nurse (MDSN) completed a 100% care plan audit for behaviors for all 95 residents to include residents at risk for sexual behaviors. Findings of the audit revealed that no other residents had inappropriate sexual behaviors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from accident hazards by not providing the proper assistive devices during a transfer. Specifically, two CNAs assisted a resident with a history of impaired vision, generalized weakness, and previous falls with a right hip fracture, from her bed to a wheelchair without using the required rolling walker as specified in her care plan. During the transfer, the resident's legs became weak, and she was lowered to the floor, resulting in her right leg going underneath her. Following the incident, the resident initially showed no signs of injury, but later complained of pain and was found to have bruising and edema in her right leg. She was subsequently transferred to the hospital, where she was diagnosed with a right tibial plateau fracture. The care plan for the resident clearly indicated the need for extensive assistance from two staff members and the use of a rolling walker during transfers, which was not followed during the incident. Interviews with the involved CNAs revealed that neither had checked the resident's care plan prior to the transfer, and both admitted to not using the walker. One CNA stated she had never transferred the resident before and questioned the technique used, while the other CNA, who had transferred the resident previously, also did not use the walker and had not reviewed the care plan. The facility's policy emphasized the importance of using assistive devices and providing adequate supervision to prevent accidents, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's legal representative following an accident involving the resident. According to the facility's policy, staff are required to immediately notify the resident, consult with the resident's physician, and notify the resident's legal representative or interested family member when an accident occurs that results in injury or has the potential to require physician intervention. In this case, a resident was being assisted from bed to wheelchair by two CNAs when her legs became weak, and she was assisted to the floor. The resident was assessed by an RN, who found no injuries at the time, and there were no immediate complaints from the resident. However, there was no documentation or indication that the resident's representative was notified of the incident at that time. The following day, the resident complained of pain in her right leg, and the physician was notified. Orders were obtained for a radiographic study, which revealed a right tibial plateau fracture. The resident's representative was notified only after these findings, and the resident was subsequently transferred to the hospital. Review of the nursing notes and interviews confirmed that the RN did not notify the resident's representative immediately after the fall, as required by facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to remove perishable food items, including milk, from a resident's room in a timely manner, resulting in the breakfast tray remaining on the bedside table for several hours after delivery. The breakfast tray, delivered around 6:30 AM, was observed still in the room at 11:08 AM, with leftover food and half a carton of milk present. Facility policy states that foods left at room temperature for several hours cannot be considered safe and free from contamination. An LPN confirmed that the resident typically ate breakfast later and that leaving the tray until lunchtime could cause the milk to spoil. The resident involved had a primary diagnosis of Alzheimer's Dementia and was assessed as moderately cognitively impaired.