SCOTTSDALE, AZ- OSBORN HEALTH AND REHABILITATION

Based on review of clinical records, resident and staff interviews, review of the State Agency (SA)

Database, and review of facility policy and procedures, the facility failed to ensure an allegation of abuse for one resident (#1) was reported to the State Agency. The deficient practice could result in allegation of abuse not reported and investigated.

Findings included:
-Resident #1 was admitted on [DATE] with diagnoses that included morbid (severe) obesity due to excess calories, chronic systolic (congestive) heart failure, depression, post-traumatic stress disorder, chronic pain syndrome, opioid dependence and anxiety disorder.

-Resident #2 was readmitted on [DATE] with diagnoses that included end stage renal disease, acquired absence of right leg below the knee, type 2 diabetes, and retention of urine.

A nursing note dated March 13, 2023 at 2:04 pm entered by a Licensed Practical Nurse (LPN/staff #29) included that resident #1 had been having verbal altercations with roommate (resident #2) all day; and that, resident #1 had threatened the roommate physically. The note included that resident #1 was upset and reported that her roommate called her vulgar/racial words and talks bad about her all the time.

The note included the roommate denied any of the allegations and then followed up with cursing resident #1 back and forth.

A social service note dated March 14, 2023 at 11:00 am included resident #1 discussed her concerns and to make a room change as soon as possible. The note included that because both residents (#1 and #2) were non-ambulatory there was a low risk for any physical altercation to occur.

Review of the clinical record and facility documentation revealed no evidence that the allegation of abuse was reported to the SA as required.

The SA complaint database revealed no evidence that the allegation of abuse was reported on March 13, 2023.

During an interview conducted with resident #1 on April 4, 2023 at 2:28 p.m., resident #1 stated that staff told her that she could not be with anyone anymore because of the incident with resident #2. Resident #1 stated that resident #2 called her a nigger; and that, staff would not believe her because resident #2 barely talks.

During the interview, resident #1 became emotional, tearful, and found it difficult to say the words resident #2 used against her. 

An interview was conducted on April 6, 2023 between approximately 11:00 a.m. and 2:00 p.m., with a certified nursing assistant (CNA/staff #17) who stated that resident #2 had a history of using racial slurs prior to being placed in the room with resident #1. Staff #17 stated that resident #2 was heard saying nigger (referring to resident #1) that’s not good enough and had yelled nigger to resident #1. Staff #17 stated that resident #2 also had said that the black people were stinking up the hallway. Staff #17 stated that she witnessed the verbal abuse of resident #2 to resident #1 on March 13, 2023; but, did not report the incident because management had been made aware of past incidents in the past and did nothing about it. Staff #17 stated that because of previous complaints being ignored, the CNA did not report the verbal racial abuse and just chose to avoid the room instead.

During an interview conducted with the Director of Nursing (DON/staff #44) on April 6, 2023 at 1:42 p.m., the DON stated the expectation was that staff would report allegations of verbal, sexual, physical abuse and exploitation right away; and that, the facility would file a report with the appropriate agencies and complete a thorough investigation. The DON stated that the verbal disagreement was investigated and the facility found it not to be a case of abuse.

A facility policy titled Abuse: Prevention of and Prohibition Against, revised in October 2022, included that each resident has the right to be free from abuse. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. All identified events are reported to the administrator immediately. All allegations of abuse will be promptly and thoroughly investigated by the administrator or his/her designee. All allegation s of abuse will be reported outside the facility and to the appropriate State or federal agencies in the applicable timeframes.

The facility policy on Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised in October 2022 revealed that in response to allegations of abuse, the facility will report no later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. The results of all investigations are reported within five working days of the incident to the State Agency.