|§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:|
§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Based on facility policy review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that staff reported an allegation of physical abuse in a timely manner for one of 25 resident records reviewed.
Review of facility policy titled "Resident Abuse, Neglect, Exploitation of Residents, and Misappropriation of Resident Property," with a revision date of December 6, 2018, revealed "6. Reporting Abuse: a. Staff members of all departments must report alleged abuse, neglect, and exploitation of residents and misappropriation of resident belongings incidents to their supervisor immediately."
Review of facility documentation revealed that on January 21, 2019, at 9:50 PM Nurse Aide (NA) 1 reported to Registered Nurse (RN) 1 that on January 20, 2019, on the 3-11 shift, Resident 41 was combative in the bathroom and NA 2 came into the bathroom to assist NA 1. NA 1 reported that NA 2 held Resident 41's arms and made a statement "that I can give it to you too."
Review of NA 1's witness statement, dated January 21, 2019, revealed that NA 2 was holding Resident 41's arms tightly so the resident couldn't slap NA 1 or NA 2. NA 1 alleges that she told NA 2 to stop holding Resident 41's hands like that because it can cause bruises and that NA 2 stated "I don't care." NA 1 also alleges that NA 2 stated "I can give to you too."
Review of facility investigation, including witness statements from NA 2, other staff members, and Resident 41, failed to corroborate NA 1's allegations. The facility unsubstantiated the abuse allegation.
NA 1 failed to immediately report the allegation of abuse.
During staff interview on May 22, 2019, at 2:11 PM the Nursing Home Administrator and Director of Nursing both stated that NA 1 should have reported the alleged abuse immediately.
28 Pa Code: 201.18(b)(1)(e)(1) Management.
| ||Plan of Correction - To be completed: 06/21/2019|
1. Resident 41 was not harmed by this deficient practice. The employee involved was educated on the importance of reporting suspected abuse immediately.
2. All staff is educated at orientation and twice a year at fall and spring in-services regarding abuse policies/procedures and reporting suspected abuse immediately.
3. All staff will again be educated on abuse policies and procedures and reporting guidelines by 6/21/2019.
4. When suspected abuse is reported, the timeline of events will be monitored to ensure that reporting is timely. Four audits will be done weekly via staff questionnaire for one quarter with random staff members to ensure that they are aware of reporting requirements.
5. Corrective action will be completed by 6/21/2019.