Mountainview Medical Center

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to implement their established policy and procedures to document and investigate allegations of reported verbal abuse and failed to report the allegations and the investigation findings to the State Agency for two allegations of verbal abuse for 2 (#s 2 and 3), and an elopement for 1 (#1) of 5 sampled patients; and failed to follow their established policies and procedures to provide on-going training to their employees on the prohibition and prevention of patient abuse for 1 (staff member N) of 7 reviewed personnel. This deficient practice has the potential to affect all patients receiving services at the facility. Findings include: 1. Investigating and Reporting Allegations of Abuse A review of the facility’s policy and procedure titled, Abuse, Neglect, and Exploitation Reporting, Investigation, and Protection, with a revision date of 2/8/21, showed: - “... REPORTING PROCEDURE 4.1 An alleged violation involving abuse, neglect, exploitation or mistreatment, injuries of unknown source, and misappropriation of property are verbally reported immediately, and within 2 hours if there is alleged abuse or serious bodily injury has occurred to the Director of Nursing, or the Social Services designee, or the [Chief Executive Officer]. 4.2 The staff member reporting the alleged violation shall additionally complete an incident in the electronic reporting system. 4.3 Within 24 hours, administrator or social services designee will report the alleged violation to the State Survey Agency. The initial “24-hour report form” for the state of Montana DPHH http://dphhs.mt.gov/qad/Certification. Certification Bureau... 6.0 INVESTIGATION 6.1 The facility Administrator, [Director of Nursing], Social Services, or the individual designated on their behalf will conduct a thorough investigation... 6.2 The results of the investigation must be reported to the certification bureau using the same electronic reporting system within 5 days of the initial incident. 6.3 The results of the investigation must be reported back to administration [Chief Executive Officer] or Director of Nursing. 6.6 Corrective action by the administration will occur depending on the results of the investigation and ongoing monitoring through [Quality Assurance Process Improvement] Committee...” a. During an interview on 6/4/24 at 9:30 a.m., NF1 stated patient #2 was admitted to the facility at the end of October 2023. NF1 stated patient #2 had called her crying stating staff member N had told patient #2 that she was too overweight to be moved in her bed and she (staff member N) and her staff would not move her (patient #2). NF1 stated patient #2 had quit asking any of the staff for further help because of the comment. NFI stated she was upset by how patient #2 was treated by staff member N and reported the incident to staff member A but had never heard any follow up about the reported incident. During an interview on 6/5/24 at 11:15 a.m., staff member A stated he did not recall an incident being reported to him regarding verbal abuse by staff member N towards patient #2. Staff member A stated it was the expectation that all incidents of abuse were reported, investigated, and depending on the nature of the abuse would be reported to the state agency. A review of the facility’s abuse reporting incidents from 10/1/23 through 6/5/24, failed to show that the incident was documented, investigated, or reported to the state agency. b. During an interview on 6/4/24 at 2:00 p.m., staff member L stated she had overheard staff member F tell patient #3 that he was going to the bathroom too much and she would not help him to use the bathroom anymore. Staff member L stated she reported the incident to staff member N at the time of the incident. A review of the facility’s abuse reporting incidents from 10/1/23 through 6/5/24, failed to show that the incident was documented, investigated, or reported to the state agency. During an interview on 6/5/24 at 11:15 a.m., staff member A stated he did not recall an incident being reported to him regarding verbal abuse by staff member F towards patient #3. Staff member A stated staff member N was the Director of Nursing (DON) at the time of the incident in question and she should have followed the facility’s process on abuse investigation and reporting. He stated she was no longer the DON and only worked at the facility as “Casual” staff. Staff member A stated it was the expectation that all incidents of abuse were reported, investigated, and depending on the nature of the abuse would be reported to the state agency. c. Review of the facility’s abuse report incidents from 10/1/23 through 6/5/24, showed patient #1 had eloped from the facility on 5/13/24. The incident was reported and documented, and investigated, but was not reported to the state agency. During an interview on 6/5/24 at 11:15 a.m., staff member A stated the elopement of patient #1 was reported and investigated but was not aware that it was a reportable incident and therefore it was not reported to the state agency. Staff member A stated patient #1 did not receive injury from the elopement and was redirected about not leaving the facility without assistance and no further incidents have since occurred. 2. Abuse Prevention Training A review of the facility’s policy and procedure titled, Freedom from Abuse, Neglect, and Exploitation, with a revision date of 2/8/21, showed, “1.0 PURPOSE To prohibit abuse, neglect, and exploitation of all patients/residents of this facility by educating employees to identify and prevent such incidents.” Review of the facility’s personnel files for on-going abuse prohibition training showed staff member N completed an abuse prohibition training presented by Adult Protective Services on 3/9/24. Additional abuse training was assigned to staff member N titled, Awareness and Reporting of Patient Abuse on 3/1/24, which was not started or completed by staff member N, as of 6/4/24. During an interview on 6/5/24 at 12:00 p.m., staff member R stated staff member N had transitioned to, “Casual” working status on 4/1/24, and had not completed the abuse prohibition training which was assigned on 3/1/24. A review of facility’s Time Worked Report showed staff member N had worked at the facility on 4/21/24. During an interview on 6/5/24 at 12:00 p.m., staff member R stated it was the expectation that all staff working at the facility complete the abuse prevention training upon hire and annual thereafter.”