An October 2019 report on Beatitudes Campus, a non-profit nursing home in Phoenix has been cited for several violations pertaining to different issues including abuse and neglect.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F 0600) Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F 0607) Report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F 0609) Respond appropriately to all alleged violations. (F 0610)
The facility failed to ensure one resident was free from sexual abuse after they were touched inappropriately by another person who appeared to be a visitor. The visitor was removed right away.
After viewing the video recording, the administrator stated that she considers this incident to be sexual assault and that it was awful that administration was not made aware of this right away when it happened.
The facility policy clearly states that the facility is to keep an environment free from abuse and that abuse is to be reported immediately.
Furthermore, the facility failed to report and investigate these issues which could lead to residents being vulnerable to further abuse.
Ensure each resident receives an accurate assessment. (F 0641)
Facility failed to ensure assessments were accurate for two residents, a practice which could affect continuity of care, result in inaccurate discharge tracking information and result in low quality or wrong data.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (F 0644)
The facility failed to ensure one resident was given a proper assessment, which could lead to a lack of proper services given to the resident.
Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F 0686)
Facility failed to ensure that pressure ulcers were monitored, assessed and documented. There was also an issue of a lack of notification to the physician to do with the development of ulcers for 2 residents. This type of non-compliance could place other residents at risk for pressure ulcer development and complications.
Ensure a licensed pharmacist performs a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F 0756)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (F 0758)
The facility put at least one resident at risk for side effects by giving psychoactive medications even though the clinical record and observations showed that they did not need them for behavior management.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F 0812)
Provide and implement an infection prevention and control program. (F 0880)
Reporting Abuse in Nursing Homes
The citations above are serious, but the most alarming is probably the fact that there are several citations related to alleged abuse, both physical and sexual, and that this was not reported properly to the right authorities.
It is state law in Arizona that healthcare providers are to report any allegations or actual incidences of nursing home abuse quickly and follow specific procedures, including contacting administration, local law enforcement, Adult Protective Services, the Department of Health Services and the Long-term care ombudsman.
A failure in the reporting process could result in a lack of protection for residents, both immediately and in the longer term. In addition, improper reporting could indicate a cover up by nursing homes if they feel they are at risk of repercussions like fines or closure, or if they feel that the incident was not urgent or important.
In the case above, the facility failed to ensure allegations of abuse for two residents and an allegation of injury of unknown source for one resident were reported to the State Survey Agency and Adult Protective Services within the required time frame of 2 hours.
If you are unsure about the privacy and confidentiality of a resident at a nursing home, reach out to one of our trusted attorneys for a free consultation.