Communication Resu1t Report Nov. 7. 2016 3 g, d' Date/Time: Nov. 2016 iihg? . File Page N9. Mada . Dest?naiion I Pg(s) Resulf? Not Sent 5303 Memory TX 716082646340 P. 36 OK Reason for error E.1) Hang up or line fa? E.2) Busy No answer 15-4) No facsimiIe conneciion E. 5) Exceeded max. E?mai] size SERVICES 166:] H. 011mm Mama mneld,WI54449 Plume: 715-334-2183 mm::k?vlnm #Pages: 6014 Aim: m? - 01/5} Facility: Fm? From: Ashleyannvsek, APSW avulnweknfr?comaniwims Phone: 715.3841] 88 3236 Comm Ls: an CONWHAL demumts womapmying ??sfacsim?: toniaia mn??m?al infomtim whim}: 1:91 ly p?v?oged. noan is oniy for 131mm :15th indi?dualorm?xy mt! nhmm. 15m arena: liminm?c? mlpimt. run an: heath} noti?ed ?nal-w (In?ll-m, copying, distime uxihot-k?xg army w?an in mliencam. the comm]: ofihis mn?dm?ai infanm?m is shictly pmhibitnd. Ifwu this ?sshnil: transmits} Emil} mar, nn??imby to 13mg: farihtmlum of (in: original (011:. Mm. - NORWOOD HEALTH CENTER WOOD COUNTY HUMAN SERVICES 1600 N. Chestnut Avenue Marsh?eld, WI 54449 Phone: 715-384?2188 Fax: 715-339?2266 FAX TRANSMISSION Date: v? If) Pages: 0014 Attn: my age} Facility: Fax: 5 LID From: Ashley Volovsek, APSW Phone: 715.384.2188 3236 avolovsek@co.wood.wi.us Comments: CONFDDENTIAL NOTICE: The documents accompanying this facsimile transmittal letter contain con?dential information belonging to the sender, which is legally privileged. The information is intended -- only for the use of the individual or entity named above. Ifyou are not the intended recipient, you are hereby noti?ed that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this con?dential information is strictly prohibited. Ifyou have received this facsimile transmittal letter in enor, please immediately notify us by telephone to arrange for the return of the original to us. Thank you. . . DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance (Rev. 04ml) STATE OF WISCONSIN DHS Wis. Admin. Code Page 1 of8 MISCONDUCT INCIDENT REPORT Use this form to report incidents of alleged misconduct (client abuse or neglect or misappropriation of client property) and injuries of unknown source. The. Department reviews this report to determine whether further investigation of the incident is warranted. So that the Department may make this determination, please complete the Misconduct incident Report in its entirety. Use the following information as guidance when completing this form. r. ENTITY INFORMATION (Page 3) The entity or facility named is the entity responsible for the care of the affected person. The Department will send all responses regarding the report to the entity reporter and address listed in this section. TYPE CODES Code Entity Type Code Entity Type 34 Emergency Mental Health Service Programs 105 Personal Care Agency 40 Mental Health Day Treatment Services for Children 124 Hospitals 61 Outpatient Community Mental Healtthev. Disabilities 12? Rural Medical Centers 63 Community Support Programs 131 Hospices 75 Community Substance Abuse Services (CSAS) 132 Nursing Homes 82 Certified Adult Family Homes 133 Home Health Agencies 83 Community Based Residential Facilities 134 Facilities for Persons with Developmental Disabilities 88 Licensed Adult Family Homes 000 Other (Specify) 89 Resident Care Apartment Complexes IV. V. . SUMMARY OF INCIDENT (Pages 3 and 4) - Indicate when the incident occurred. Include the month, day, year, and time of the incident 0812512003, 10:30 AM). If you do not know the exact day, provide an approximate date the week of March the month of March, between March 1 and April 15). If you give approximate dates, explain how you determined the dates. - Briefly describe the incident. Summarize the incident in the space provided, even if more details or documents are attached. - Describe the effect of the incident upon the affected person or the person?s reaction to the incident. if a person has been physically injured, describe the injury, the size of the bruise, etc. A photograph of the injury is very helpful. if photographs are taken, identify when the photos were taken, how many were taken and by whom. Describe any indication or expressions of pain, anger, frustration, humiliation, fear, etc. by the person during or after the incident. - Explain what: the entity did, upon learning of the incident, to protect the person(s) from further potential misconduct. Describe the steps that the entity took to protect the person(s) from subsequent potential episodes of misconduct while a determination on the matter is. pending. indicate the accused person's current employment status and date of any employment action after the alleged incident. NOTE: The entity is not required to terminate the employment of an accused person to meet protection requirements. - Check the speci?c location where the incident happened. if the incident happened at a location other than the entity, indicate the speci?c address of that location. AFFECTED PERSON (Page 4) Include the affected person?s name, date of birth, gender, address, and telephone number. If the affected person has been adjudicated incompetent, is under age 18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of the parent, guardian, or legal representative. ACCUSED PERSON (Page 4) Include the accused person's name (if known), social security number, position or titie at the time of the incident, date of birth, gender, current home address, and home telephone number. Entities must inform the accused person that a report regarding the incident is being ?led with the appropriate authority. lithe accused person is currently employed by an entity other than the reporting entity, include the name, address, and telephone number of the current employer. lfthe accused person is under age 18. provide the name, address, and telephone number of a parent or guardian. if there is more than one accused person, complete this section for each person. LAW ENFORCEMENT (Page 5) Check if law enforcement was contacted or is inVolved. Indicate the of?cer?s name, department, address, telephone number, and-?if available- --the case number. Attach a copy of the law enforcement incident report, it available. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT (Page 5) include all persons with speci?c knowledge of the incident. include the person?s name, gender, address, and telephone number. Check whether the person is an entity employee. include the person?s position at the entity or relationship to the affected person. Attach additional pages, as necessary. F-62447 (Rev. 04/10) vn. DESCRIBE on ATTACH A COPY or THE RECORDS CONCERNING THE Incrd?ntr (baggie) Ii Page ,2 ,ofB Provide all relevant information found during the entity?s internal investigation, including the following: STAFF INFORMATION Accused individuai?s personnel records, including but not limited to training records, disciplinary records, time cards or sheets for the period during which or date(s) the incident occurred. Witness time cards or sheets for the period or date(s) the incident occurred. Staff schedule, roster, or assignment sheets for the time period or date(s) the incident occurred. Statements from the accused individual and witnesses relating to the incident. Sign-off sheets indicating completion of cares pertinent to the incident. CLIENT INFORMATION Pertinent medical records, including but not limited to the person?s plan of care or treatment plan at the time of the incident. Ambulance run report, if applicable. Any relevant hospital admission and discharge documents. Photographs of visible injuries or affected property. Financial account statements, including account numbers and balance information. Statements about the incident. ENTITY Entity's policies and procedures related to the incident. Photographs and diagram or illustration of the scene where the incident occurred with relevant information included, locations of witnesses, client, and pertinent objects at the time of the incident. PERSON THIS REPORT (Page 6) Provide the name, position or title, and telephone number of the person preparing this report. The person preparing this report must sign and date this form in the space provided. . WRITTEN STATEMENT (Page 7) LAW ENFORCEMENT INFORMATION Law enforcement of?cer?s narrative reports. Photographs. OTHER INFORMATION Any other records that may apply. - Ask the affected client, the accused person, and all other persons with information about the incident to provide written statements. - If the entity uses its own forms to obtain written statements about the incident, the entity may attach those forms to the incident Report. if the entity attaches its own written statements to the report form, the facility should ensure that each person completing a written statement provides the identifying information requested on the report form and signs the statement. - The entity is advised to follow up on written statements by asking probing questions to gather as much detail as possible, including what happened, how the incident happened, when it happened, where it happened, reactions at the time of the incident, and other witnesses who may have been present. it is suggested that the entity use the FOLLOW UP QUESTIONS (Page 8) following the written statement form as a guide when questioning the accused person. 3.5 Eii: 1:253:41. '55 FEDERALLY CERTIFIED NURSING HOMES AND FEDERALLY CERTIFIED CARE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES Upon the completion of the entity?s internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within 5 WORKING days (Monday Friday, excluding legal holidays) of the date the entity knew or should have known of the incident. ALL OTHER ENTITIES Upon the completion of the entity's internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within 7 CALENDAR days of the date the entity knew or should have known of the incident. 5 NOTE: All complaints regarding both credentialed staff RN, LPN, MD) and non credentialed staff nurse aides, personal care workers, housekeepers) will be tracked by the Department of Health Services, Division of Quality Assurance (DOA). DOA will refer complaints that involve credentialed staff to the Department of Regulation and Licensing for investigation. Send the completed form and any supporting documentation to: Department of Health Services Division of Quality Assurance Office of Caregiver Quality P.O. Box 2969 Madison, WI 53701-2969 You may also send forms via: E-mail: Fax: (503) 264-5340 DIRECT QUESTIONS REGARDING THIS FORM TO (608) 261-8319. STATE OF DHS Wis. Admin. Code Page 3 of 8 DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance (Rev. 04H 0) MISCONDUCT INCIDENT REPORT Completion of this form is required by DHS Wis. Admin. Code. Failure to file a complete and accurate report of an incident of alleged misconduct, as required. may subject the entity to forfeiture or other sanctions speci?ed by the Department under DHS Wis. Admin. Code, and may delay the investigation process. Personal information will be used to investigate the reported incident and the results of the investigation may be shared with other authorized investigative agencies. This report form must be completed in its entirety. Additional information may be attached. TYPE 0R PRINT NEATLY lN BLACK INK. - . - . ?i?t .1 .. t. .ENTITXJNEQRMATION lit-fijvf-?stit-f? i Name Entity or Facility Telephone Number NORWOOD HEALTH CENTER 715?334?2133 Street Address County Federal Provider or Certi?cation No, 1600 CHESTNUT AVE WOOD 52A460 City State Zip Code State License, Approval, or Registration No. MARSHFIELD WI 54449 5027 Name ?Administrator Entity Type Code (See instructions.) JORDON BRUCE 132 tiff-5.9. MARYCEINCID when the incident occurred. if the exact date and time are Date Occurmd unknown. make a reasonabte estimate and indicate that the date and time are estimated. include the date the incident was discovered, it other than the date the incident occurred. 10?28'2016 8 PM BRIEFLY THE INCIDENT in the space below. Summarize the incident here even if additional documentation is attached. C.N.A Arlene Dampier indicated to sopervisor ari Lupke RN on 10?31?16 11am that she witnessed RN Rosemary Carlson direct C.N.A Carlie Schreiner to hold residen hands down so she can administer medication. Date Discovered (mmiddiccyy) 10?3 1?1 6 Time Occurred DESCRIBE THE EFFECT that the incident had on the affected person, the person?s reaction to the incident, and the reaction of others who witnessed the incident. Resident? his highly impaired cognition due to a traumatic brain injury. He is unable to verbalize effects, RN assessment indicates no physical effects from the restraining incident. .cannot recall the incident nor verbalize any staff who have helmed him. C.N.A Arlene Dampier appears emotionally upset by incident. RN Rosematy Carlson does not appear to have effects from incident. C.N.A Carlie Schrenier does not appear to have effects from incident. No other witnessed identi?ed. (Rev. 04110) EXPLAIN what steps the entity took upon learning of the incident to potential misconduct. Page 4 of 8 1? protect the affected person(s) and others from further Ensuredsafety of all residents, itmnediately suspended involved staff pending investigation, Education to all staff inunediately on reporting abuse/neg}act/misappropriation per policy, Phone call interviews to all staff members working. 10/27-10/31 inquiring potential indicators of safety concerns, verbal nonverbal treatment of residents by staff or suspicions of inappropriateness, towards themselves or others All LTC residents surveyed for safety, inquires of witnessing any staff being-mean/verbal or abusive CHECK the specific location where the incident happened. At Your Entity El During Transport Another Location Explain: til. AFFECTED PERSON INFORMATION if more-than one, include additional pages. Name Affected Person Date of Birth Sex- Male Female Address Telephone Number 1600 CHESTNUT AVE City I I Sta Code MARSHFIELD WI 54449 lf the affected person is adjudicated incompetent or under ?18, or has an authorized Power of Attorney for Health Care, include the name, address, and tetephone number of parent, guardian, or tags! representative Name Gardi?. or Power of Attorney pho Tele ne Number IV. Name - Aorzused Person (if known) ROSEMARY CARLSON ACCUSED PERSON INFORMATION it more than one-include additional pages. Position or Title or Relationship to Affected Person (at the time of?the. incident? RN Sex Male Female El Resident El Non Credentialed Staff Credentialed Staff Other: List any known credential held by the accused at time of the incident; RN, LPN, social worker, security guard, professional counselor. RN Home Street Address Home Telephone Number ode lf employer is other than the reporting entity, provide information about accused person?s current employer. Name Employer Sex Telephone Number El Mate El Female Street. Address City State Zip Code NOTE: If accused person is under 18, provide parent(s) or guardian information. Namets) - Parent or Guardian Sex Male Female Telephone Number Street Address City State Zip Code (Rev. 04f10) Page 5 0f 8 vi LAW ENFORCEMENT INVOLVEMENT if Was law enforcement contacted or involved? ?1 No Yes If "yes," complete the following. Attach a copy of the law enforcement incident report, if 'avaiiebie. Name -'Officer (if available) Department OFFICER KRANTER MARSHFIELD POLICE DEPARTMENT Street Address Case Number (if available) 110W ST . 16?16486 City State Zip Code Tetepbone Number MARSHFIELD WI 54449 715?3 84?3 1 13 VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE INCIDENT if more space is necessary, attach additional pages. Name - Person who REPOETED Incident to the Entity - Sex - ARLENE El Maze Female StreetAddre's?sm Telephone Nber Zip Code Is this erson an ENTITY Yes El No motion in the Entity o?r Relationship to the Affected Person CNA Name - Person With Information About the Incident Sex JORDON BRUCE Male 13 Female Address Telephone Number 1600 CHESTNUT AVE 715-3 84-2188 City I State Zip Code is this person an ENTITY MARSHFIELD WI 54449 Yes El No Position in the Entity or to the Affected Person ADMINISTRATOR Name - Person with Information About the Incident 'S'ex ELIZABETH MASANZ Male Female Address I i I Tote-phone Number 1600 CHESTNUT AVE 715-3 84?2188 City . State Zip Code is this person an ENTITY MARSHFIELD WI 544449 53 Yes El No Position in the Entity or Reiatibnsbip to the Affected Person I DIRECTOR OF NURSING Name - Person with Information About the Incident Sex MARIA LUEPKE Male Female Address Telephone Number 1600 CHESTNUT AVE 715?3 84?2188 City State Zip Code is this person an ENTITY MARSHFIELD WI 54449 Yes El No Position in the Entity or Relationship to the Affected Person HEAD NURSE Name - Person with information About the Incident Sex ASHLEY VOLOVSBK El Male Female Address Telephone Number 1600 N. CHESTNUT AVE 715?3 84?2188. City State Zip Code is this person an ENTITY MARSHFIELD WI 54449 Yes El No Position in the Entity or Relationship to the Affected Person SOCIAL WORKER (Rev. D4f10) Page 6 of 8 eemeb?ir?e - PLEASE SEE ENCLOSED vru. Reason PREBARING REPORT Sf?eamrng??t?af'in emit m) Name - Person Preparing This Report ENTITY Position in the Entity or Relationship to the Affected Person ASHLEY VOLOVSEK Yes El No SOCIAL WORKER Street Address City State Zip Code 1600 N. CHESTNUT AVE MARSHFIELD WI 54449 Email Address Telephone Number 715?3 34-2188 - Person Preparing This Report Date Signed 0, 0% WW 13?62447 (Rev. 04MB) Page 7 of tX. EWIRITTEN STATEMENT 212?," 32'; - 15'? - 1' Use this page to colteci written statements from the accused person, affected person, and witnesses regarding incidents of aiieged misconduct (abuse or negiect or misappropriation of property). Make additional copies of this page as necessary. Completion of this form is votuntary. it is suggested that entities ask the questions on the following page to obtain additional information and detail about reported incidents. Please record ail responses given. Entities may use their own forms; however, any written statement must be attached and submitted with the Misconduct Incident Report (DQA form Section 1 - To be compieted by Entity Brief Description of Alieged Incident "Marion R's broken arm.? ?the theft of Marion R's credit card,? "Marion R?s felt") Section 2 I- To be completed by Accused Person, Affected Person, or Witness Full Name (Last. First, Middle Initial) Home Telephone Number Street Address Work Telephone Number City State Zip Code Position or Titie or Relationship to the Affected Person Section 3 To be completed by Accused Person, Affected Person, or Witness Provide as much information as you know about the incident described above. Tell what you know about the incident in detail. Use additional pages, as needed. Check if additional pages are included. SIGNATURE Accused Person, Affected Person, or Witness Date Signed (Rev. 04110) Page 8 of FOLLOW UP QUESTIONS T0 BY THE ENTITY it is suggested that entities ask the following questions to obtain additional, detailed information about reported incidents. Please record ail responses in the spaCe provided. Attach additional pages, information, documentation, diagrams, photographs, or other evidence as appropriate. El Check if additional pages are included. Check if items or documents are attached. Check if a photocopy of an item or document is attached. El Check if an item or document is being retained by the entity; describe where and how it is being stored pending the outcome of?this investigation. a How do you know about the above incidenthappen to you? Did you see it? Did another person tell you of it? if A so, who? Time and date of the incident. When did it happen? When did you ?rst learn about it? - Location. (Where. did the incident occur? Where were you when it happened? if others were present, who and where were the others? Where Were you when you learned about it or saw it? Describe the location. Attach a diagram.) Was anyone also present when it happened, you learned about it, or when you saw it? if so, who? Where was each person? - Did you tell anyone about the incident? if so, what did you tell them, who did you tell and when did you tell them? What did the person say, if anything? - Was anyone harmed in any way (physically or sexually, emotionaliy or mentally, or ?nancially) or could someone have been harmed? if so, describe the harm or potential harm. - Were others harmed in any way? if so, identify the person who was harmed and describe the harm. - Describe the affected person's actions or reactions during the incident inciuding statements made, changes in demeanor, or other indications of pain, fear, sadness, anger, humiliation, etc. a Describe-the actions or reactions of others who observed or were involved in the incident. - For Affected Persons: Did you tell anyone about whathappened to you? if so, who did you tell and when and where did you tell them? i For Other Witness-es: is or was the affected person able to report or talk about the incident? if so, did the affected person say anything to you? if so, what? Describe the way that the affected. person acted when telling you about the incident. - To your knowledge, did-the affected person tell anyone else? if so, who and when? Are there others who know or may know about the incident? if so, who are they and why do you. think they have information about the incident? - Do you have or are you aware of any evidence, documentation or information that may be relevant to the incident? (Examples: photos, diagrams, maps, receipts, video tapes, audio tapes, medical records, care plans, ?nancial transaction records, etc.) if so, what is it and where is it? Additional Information Name Person lntervie?Wed Name - Person Conducting the lntenriew Interview Date Arlene Dampier 10-31v2016 1100 Statement Friday 10?28?2016 Arlene returned from break to Pathways, heard a noise from resident room. Arlene went to room found Rosie RN and C.N.A Carlie Schreiner i bedroom. Rosie was administering medication to Eniouth with her ?ngers 85 C.N.A Carlie was holding hands down while was lying in bed being combative. Arlene stated ?He usually takes his medication with pudding?. Rosie directed Carlie to go get pudding, which she did returned to bedroom. Rosie used the pudding with medication in it and continued to administer to did spit one pill out which fell to the ?oor. Arlene witnessed Rosie move it?? bed to retrieve the medication, picked it up off the ?oor used her ?nger to administer pill to mouth. After medication was administered, Rosie looked at C.N.As and stated ?Don?t tell anyone about this? Arlene 85 Carlie did not discuss incident; they each ?nished their shifts. 11-1?20 1 6 1105 Statement Rosemary Carlson RN Rosie does not recall anything unusual occurring on 10/27 or 10/28 PM shifts. Rosie could not recall anything unusual occurring on her shifts Thursday or Friday PMs. She stated - was resisting medications and she asked Carlie to hold hands so meds could be given. Rosie indicated if there was a ?real? reason irefused his medications, then she would accept refusal. She went on to say if a resident can?t give a ?real? reason then she gives medication. When asked about medication falling on the ?oor, Rosie denied allegation stating that the medication did not fall on the ?oor that she can recall- if ineds fall on ?oor they are to be thrown away. Rosie admitted to Arlene being in the room at the time, but doesn?t know why Arlene was in :?32'ir5i room. Rosie understood no restraints are to be used in a she relays understating restraints as tying someone down or removing their mobility device. Rosie admits to telling Carlie to hold hands down so he doesn?t hit her. She stated opened his mouth took the medication. She denies stating to ?Don?t say anything?. Rosemary denies all other allegations, but admits to asking Carlie to hold. hands down. She states she is mysti?ed why she was called with suspension and reasons giyen. Rosie informed of report to law enforcement potential further investigation. Norwood to contact Rosie when investigation is complete, Rosie is on no contact with building/peers except Administration. assist with giving his medications. Rosie asked Carlie to hold arms dowii as he was being combative and did not want to take his pills. Carlie then asked ?why not crush them and give them via the PEG tube since he doesn?t want to take them? and Rosie stated don?t want to do that because l?rn already too behind?. Rosie tried to give them on the spoon and he kept refusing. Then she picked them up with her fingers and tried to put them in his mouth and he still refused. Rosie rubbed her finger on his lips to try to get the pills in. Arlene CNA entered the room when pit the pill onto the floor. Rosie pulled the bed out and got the pill on the floor. Someone stated to try pudding and Rosie stated yes. Carlie then went to get the pudding and Rosie put the same pill in the pudding and tried to give it to continued to spit it out and so Rosie used her finger again to attempt to place the pill with the pudding 'into his mouth and she again rubbed her fingers on lips to make him take the pills. did swallow the pill at this time. Rosie was then cleaning up her supplies and Arlene was fixing the blankets and Carlie was cleaning the pudding off of face. Rosie then stated, want neither of you to breath a word about this" then turned and walked out of the room. Page Ii of; 0-28?2016 I Rosemary Carlson RN, Arlene Dampier C.N.A, Carlie Involved Parties; Resident Schre?iner C.N.A Ancillary stay? Jordon Bruce Admin, Elizabeth Masanz DON, Maria Luepke HRN, Ashley Volovsek SW Incident: A per Arlene Danipier C.N.A statement: 10?28?20] 6 8PMRN Rosie was in resident room with C.N.A Carlie. C.N.A Arlene allied into room as she heard ozse at 7143 Car! 1?3 @363ng .. .. hands down while as lying in ad dc Rosie attempting to administer medications to Arlene stated 5 e- wit essed a pill fall to the?oor, saw Rosie move bed Pick up mication andput it in mouth. Arlene she was suspended pending investigation 85 escorted out of building 10l3 1/ 16 1110. Arlene instructed not to disclose any information to any staff except Police, Admin, DON, HRN SW as part of investigation. Jordon Admin updated 1 120. 1125 Carlie chreiner was interviewed by Maria 86 Ashley, Jordon present via telephone. Statement obtained, Carlie suspended and escorted out of building by Maria 1145. About 1200, Maria RN called Rosemary-to inform she?s been suspended pending an investigation 85 needs to report to Nor-wood 11/1/16 1100 for a meeting'with Admin. 1400 SW Ashley completed online report of potential abuse to Marsh?eld Police Department was called 1400. Of?cer Landon Kararner assigned to investigation case it 16- 16486, he came to Norwood 1415 to speak with Maria RN regarding incident. Dr. Espada updated by Liz, DON of allegations pending investigations. 1500 Liz Masanz DON updated. 1545 Debra Hilger, wife/ Guardian of Jeffrey Hilger updated. 11/1l1?6 1100 Rosemary was interviewed. by Jordon, Liz dc Maria. 1415 Carlie C.N.A interviewed by Jordon, Liz, Maria 85 Ashley. Education provided on following policies, discipline issued. Carlie cleared to return to work PM shift this date. Contributing Factors: 9 'has decreased decision making abilities due to traumatic brain injury status: legal Guardian is Wife .displays con?is'ion, inattention, impulsivity due to TBI status 9 ?3 assist of 1 with ambulatioanDLs .has impaired vision as the TBI resulted in bilateral damage Intervention: 'EdUCation initiated to all staff immediately before working ?oor (abuse neglect restraint policy) Education at Unit meeting 10/31/16 on reporting abuse/neglcot/misappropriation per policy Page 2 of2 Mandatory Training scheduled on reporting abusefneglect per Norwood policy scheduled facility wide for November 2016. a Phone call interviews to all staff members working 10127?10/31 inquiring potential indicators of safety concerns, verbal nonverbal treatment of residents by staff or suspicions of inappropriateness a All residents surveyed on both units (Crossroads Pathways) for safety, inquires of witnessing any staff being mean/verbal or abusive towards themselves or others 6 Initiated Audit to ensure staff comply with understating appropriate policies Conclusion Rosemary: Carlson did admit to forcing medications with resident . follow abuse/neglect policy as well as restraint policy by ordering C.N.A Carlie Schreiner to ii. hands down during medication administration. does not have capacity to recall/remember incident due to altered cognition from traumatic brain injury. He could not recall any unusual incidents occurring over the past week. He states he feels safe not afraid here. He doesn?t think anyone would hurt him. No other witnessed identi?ed. aim/v Ashley Vol?elg APSW I Date CC: Jordon Bruce, Admin. Elizabeth Masanz, DON Maria Luepke HRN Ashley Volovsek From: Sent: Monday, October 31, 2016 1:03 PM To: Ashley Volovsek Subject: Alleged Nursing Home Resident Mistreatment Report Thank you for submitting an Alleged Nursing Home Resident Mistreatment Report to the DHS Division of Quality Assurance (DQA). Upon completion of the facility?s investigation and within 5 working days of the date discovered, submit a completed Incident Report (E62447) to the DQA Of?ce of Caregiver Quality. Questions about reporting requirements or investigation status may be directed to the BOA Of?ce of Caregiver Quality at DHS or 608?261 ?8319. SURVEY RESPONSES 1. Facility Name Norwood Health Center 2. State License Number 502?? 3. Street Address 1600 Chestnut Ave 4. City Marsh?eld 5. County WOOD 6. Zip Code 54449 7. Date Occurred 10/293016 8. Time Occurred (include AM or PM) approximately 9. Date Discovered 1 0/3 1/201 6 10. Allegation Type ABUSE Survey Results Page 1 of 3 Hide/Show 15 Fiat Iools ?3 e??eged Nursing Home Resident Mistreatmen?: Report (@6261?) User Information Name: Anonymous Emai?: Location: Company: Position: 32? Address: 66.170.171.51 Started: 10f31/2016 11:02:12 AM Compieted: 10/31/2016 11:03:28 AM 0 days, 0 hours, 1 minutes, 76 seconds, 76000 milliseconds cu?tum 1: WA Time Spent: Custom 2: Custom 3: NM "in Facility Name Nor-wood Heaith Center 2. State Lic?ense Number 5027 3. Street Address 1600 Chestnut Ave 4-. City Marshfield 5. County WOOD 6. Zip Code 54449 7. Date OCCurred 10/29/2016 nalnn+b11r1 max-r moi-thQ 10/21 {9016 Survey Results Page 3 of 3 61 &Ing0uesti 1 0/3 I {201 6