Additonal abuse incidents involving other disabled persons under Paluch's care include:
1. Auditor's review of incident reports for the facility revealed that on 7/20/09 at 6:30 A.M., supplemental sample individual #6 had a bruise on her left arm "about the size of a baseball about 5 inches above (her) wrist."
The incident report contained a "Medical Review" form that indicated the facility nurse was notified by phone on 7/20/09 of the injury to individual #6. The nurse conducted a phone evaluation and documented, "Reported as 1" (inch) x 3" red area. No further medical follow up was required. There was no evidence that a complete assessment of the injury was conducted and documented to accurately describe the injury.
The incident report had a section for staff to document what was happening immediately prior to the incident occurring. The staff documented, "unknown." Another section documented that the injury could have possibly occurred due to the individual biting her arm. The incident report contained no further follow up.
The QMRP (Qualified Mental Retardation Professional) was interviewed on 11/4/09 at 1:50 P.M. The QMRP stated that the incident was not referred to the Quality Assurance Department because s/he had determined that the individual was biting their wrist. When the QMRP was asked how this determination was made, s/he stated that it was determined by what staff had said and where the injury was located. The QMRP was unable to provide written evidence that a thorough investigation had been conducted to determine the cause of the injury and ensure that no abuse had occurred.
2. Auditor's review of incident reports revealed sample individual #3 was discovered to have three scratches on her right arm on 10/14/09 at 8:00 P.M. Two of the scratches measured one half inch and one measured approximately two inches in length.
The incident report indicated that immediately prior to the incident, individual #3 was at her day programming location. The incident report further documented that individual #3 "indicated that it happened at (day program)."
The incident report contained an assessment by the nurse, dated 10/14/09 at 5:30 P.M. The nursing assessment documented that the nurse had assessed the injury and that it looked to be a "minor old healed abrasion." The nurse further documented that they requested the house staff member document the injury on the "potential injury log" but that the house staff member "insisted it needed further f/u (follow up)/investigation." The injury was again assessed by the nurse on 10/15/09 and no further follow up of the injury was indicated.
The incident report indicated that one staff member from individual #3's day program site was interviewed and reported that no incidents occurred at the day program site to cause the injury. Five days later, individual #3 was again interviewed and asked if the injury occurred at day program. The individual then indicated that the injuries did not occur at the day program location.
The QMRP was interviewed on 11/4/09 at 1:50 P.M. The QMRP stated that s/he called the day program staff and spoke to them about the incident. Although the cause of the individual's injury could not be determined, the QMRP did not refer the incident to the Quality Assurance Department. Further, the QMRP was unable to provide any written evidence that the incident was thoroughly investigated to rule out any potential abuse.
0 comments