Carlyle Senior Care Of Aiken

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 deficiency involves the facility’s failure to protect a cognitively impaired female resident, R3, who lacked capacity to consent, from sexual contact initiated by another resident, R2. R3’s records showed a diagnosis of unspecified dementia with behavioral disturbance and a need for substantial to maximal assistance with ADLs. R3 wandered throughout the facility and required a helmet when out of bed due to multiple falls. R2’s records showed diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other sexual dysfunction not due to a substance or unknown physiological condition. His MDS indicated he was unable to complete the BIMS interview and required partial to moderate assistance with ADLs. R2’s medical record documented a history of periods of inappropriate behavior and inappropriate gestures toward staff during personal care. His care plan identified a history of pulling at his penis, inappropriate behavior, and inappropriate gestures, with an approach to monitor and record occurrences of hypersexuality toward staff, inappropriate responses to verbal communication, and violence or aggression toward staff or others. Despite this documented pattern, the facility did not prevent an incident in which R2 engaged in sexual contact with R3. On the night of the incident, a CNA walking down the hall observed R2 lying naked on his bed and R3 kneeling beside the bed, with R2’s hand over R3’s hand, placing it on his genital area. The CNAs’ and Unit Manager’s interviews consistently described R2 as unclothed from the waist down and R3 as fully clothed, with R2 using his hand to guide R3’s hand onto his penis and attempting to pull her into the bed. CNA2 initially saw the interaction, left to seek help, and returned with CNA3, who positioned herself between the residents to separate them. When the Unit Manager arrived, she observed R3 on the floor beside the bed and R2 on the bed, and while assessing R3 for injury, noted R3’s hand under R2’s cover with the cover moving. The Administrator confirmed that both residents were nonverbal and unable to have appropriate communication, that R3 wandered throughout the facility, and that R2 usually remained in his room. The State Agency determined that the facility’s noncompliance with 42 CFR §483.12, Freedom from Abuse, Neglect, and Exploitation, resulted in Immediate Jeopardy related to the failure to ensure R3 remained free from sexual abuse.

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 occurred when a resident with severe cognitive impairment and a known risk for elopement was able to exit the facility unsupervised. The resident, who had diagnoses including vascular dementia with behavioral disturbance, psychotic disorder, and delusional disorder, was assessed as being at risk for elopement and wore a WanderGuard device daily. On the day of the incident, the resident was last seen by staff in the early morning, after which he was able to leave the building through a service hall door without staff noticing his absence immediately. The facility's policy required that residents at risk for elopement receive adequate supervision and that exit doors be equipped with alarms to prevent unauthorized exits. Despite these measures, the resident exited through a service door that was supposed to be alarmed. Staff initiated a search after realizing the resident was missing, conducting multiple checks inside the building before expanding the search outside. The resident was eventually found across the street on school grounds, having left the facility without injury. Interviews with staff confirmed that the resident's WanderGuard was functioning, but the door alarm did not sound due to damaged wiring. Further investigation revealed that the service hall door's alarm system had frayed wiring, which rendered the alarm ineffective and allowed the resident to exit undetected. The door in question was primarily used by dietary, maintenance, and laundry staff and was not a typical route for the resident. Facility leadership acknowledged that the damaged alarm wiring was likely caused by the high volume of equipment and personnel using the door. The failure to maintain the alarm system in working order and to provide adequate supervision for a high-risk resident led to the resident's successful elopement.

Removal Plan

• The wander guard for Resident DC was checked and found to be fully operational.
• A subsequent check of the wander guard revealed it was still functional.
• A comprehensive assessment of Resident DC was conducted, and it was documented that there were no injuries or any signs of distress.
• Resident DC was placed under 1-on-1 supervision for close observation and monitoring.
• A detailed inspection of the wander guard system at the facility's service hall exit uncovered that a wire had come loose, which directly impacted the alarm functionality of the door. This issue was promptly addressed, with the maintenance supervisor completing the necessary repairs.
• A backup alarm was installed on the interior door leading to the service area.
• A comprehensive check was performed on all other residents utilizing wander guards to verify their integrity and functionality, ensuring that no other residents were at risk of elopement.
• An accurate headcount of all residents was conducted to confirm that everyone was present and accounted for within the facility, ensuring the safety of all our residents.
• All exits were thoroughly inspected to verify that backup alarms were present and operational. This meticulous check confirmed the effective functioning of all backup alarms.
• An audit was carried out to identify residents who had undergone risk assessments related to potential elopement. This included a review of care plans to ascertain that interventions, such as the use of wander guards, were adequately addressed and implemented.
• Resident DC's care plan was updated to reflect the new risks associated with elopement incorporating specific interventions tailored to ensure his safety.
• The maintenance supervisor will perform inspections of the entire wander guard system and all backup alarms for every door to ensure they are functioning correctly.
• The wander guard alarm on 60 hall does not function, but the backup alarm functions and a stop sign has been placed over this door.
• All nursing staff across all shifts received training on resident safety protocols, specifically focused on checking alarms and monitoring wander guards. Any staff members on leave will receive this educational briefing upon their return to work.
• Agency staff will undergo training on these protocols before commencing their shifts.
• New hires will receive targeted training during their orientation regarding wander guard monitoring, alarm response procedures, and general resident safety.
• The Minimum Data Set (MDS) nurse will conduct audits of new admissions for elopement risk and ensure that appropriate safety interventions are put in place without delay.
• The maintenance supervisor will monitor alarm functionality daily for two consecutive months, moving to a weekly schedule thereafter. The results of this ongoing observation will be reviewed weekly by the facility administrator to ensure consistent compliance.
• Newly hired staff will receive dedicated training on topics related to wandering, elopement, and overall resident safety from the in-service coordinator during orientation.
• A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) has been implemented to systematically review and analyze all audit findings.
• The results of the alarm monitoring will be reviewed in the QA meetings monthly for three months, then quarterly, until it is determined that the deficient practice is not likely to recur.

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 allegation of abuse involving a resident within the required 2-hour timeframe. The facility's policy mandates immediate investigation and reporting of abuse allegations to the Administrator, state agency, adult protective services, and other required agencies within 2 hours if the events involve abuse or result in serious bodily injury. However, Nurse 1 did not report the allegation made by the resident, who stated that a man came into her room and touched her breast. Nurse 1 admitted to not taking the allegation seriously at the time and failed to notify the abuse coordinator. The incident was only discovered when the resident spoke with Social Services during an interview about abuse, who then reported it immediately. The resident involved had a history of major depressive disorder, hyperlipidemia, hypertension, and cerebral infarction, and was moderately cognitively impaired with a BIMS score of 9 out of 15. The Director of Nursing confirmed that the allegation was not reported by Nurse 1 and reiterated the policy that any type of abuse must be reported within 2 hours. The failure to report the abuse allegation promptly led to a deficiency in the facility's compliance with its abuse reporting policy.