Severe reports

In plain words: The facility failed to ensure a doctor was told about an alleged physical abuse incident involving a patient. The facility also failed to ensure a doctor examined the patient within twelve hours as required. Our summary of the state's report. The state's own wording follows.

Based on review of facility documents, clinical record review and staff interview it was determined the facility failed to ensure the Program Manager or the Nursing Supervisor notified the Attending Physician of the allegation of physical abuse and the facility failed to ensure the Attending Physician or the Medical Director assessed Patient #1 within twelve (12) hours of the alleged physical abuse per facility policy. [...] The attending physician or the Medical Director may order that the patient be transferred to Charleston Area Medical Center for evaluation of physical or sexual abuse allegations." 2.

From the state's report. Deficiency cited, complaint survey. Cited: N 196 483.372(a) MEDICAL TREATMENT FOR INJURIES. "[...]" marks text left out between sentences.

(b) Review of the medical record for Consumer #1 revealed a swallowing evaluation was completed on 06/16/04. This swallowing evaluation revealed the following: "There was frank laryngeal penetration and tracheal aspiration upon ingestion of thin and thick liquid and puree material. [...] Theses issues were identified as needs as early as 03/13/06, almost one (1) year prior to the death of the consumer.

(xi) On 2/12/07 at approximately 12:30 p.m., while at the day program, Consumer #1, aspirated a piece of hot dog and died.

These issues were identified as needs as early as 03/13/06, almost one (1) year prior to the death of the consumer.

From the state's report. Deficiency cited, complaint survey. Cited: C 242 64-11-7.3.c. Treatment Plan; C 123 64-11-5.5.b.4. Center Responsibility; C 240 64-11-7.3.a. Treatment Plan. "[...]" marks text left out between sentences.

Bipolar, ODD, ADHD, Schizophrenia, Substance abuse, and physical sexual abuse.

From the state's report. Deficiency cited, survey. Cited: C 119 64-11-5.5.a. Center Responsibility.

Findings include: (a) Consumer #7 alleged on 6/15/01 that Staff A had sexually abused the consumer by the staff grabbing his crotch on three (3) separate occasions. [...] (b) On 8/23/01, the Center reported to the State IIU that Consumer #5, #6 and #3 alleged that they had been improperly restrained by Staff B and had sustained injuries as a result, over a two (2) week period of time. [...] (c) On 11/28/00, Consumer #8 alleged that Staff C dragged him across a room, pulled his arm and pushed the consumer into a chair two (2) weeks earlier.

From the state's report. Deficiency cited, survey. Cited: C 359 64-11-8.2.b. Violation of Consumer Rights. "[...]" marks text left out between sentences.

(b) While Consumer #6 alleged abuse (staff kicked him in the mouth) during the restraint which resulted in his assault charge, the abuse allegation was investigated internally. [...] (c) Consumer #1 was inappropriately restrained by Staff #30 on 3/17/01. [...] The consumer suffered a sprained wrist, requiring a trip to the emergency room, during the restraint. [...] Findings include: (a) Staff #5, according to internal investigation, was negligent in her duty to supervise Consumer #7 when he eloped on 1/29/01.

From the state's report. Deficiency cited, survey. Cited: C 102 64-11-5.2.a. Governing Body. "[...]" marks text left out between sentences.

For example, Consumer #1 hit his head on the wall and cursed staff on 5/6/00, 5/8/00, 5/15/00 and hit himself in the face on 5/21/00. On 5/15/00, the consumer injured himself so badly that he had to be taken to the emergency room of a hospital for treatment of his head injuries.

From the state's report. Deficiency cited, survey. Cited: C 243 64-11-7.3.d. Treatment Plan.