|§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 a review of clinical records, information provided to the State Agency via the Electronic Reporting System, electronic email communication with the facility and staff interview, it was revealed that the facility failed to provide evidence that all instances of alleged resident abuse were thoroughly investigated and the complete results submitted to the State Survey Agency within five working days of the incident as evidenced by two of seven allegations of abuse reviewed (Residents 2 and 3 ).
According to review of incidents of abuse, neglect and misappropriation of property, the facility reported the following incidents to the State Survey Agency via the Electronic Reporting System (ERS) but failed to report the completed investigative findings and corrective actions taken in response to the following allegations of abuse as evidenced by the facility's failure to submit a complete PB22 (Pennsylvania Bulletin 22- form used to detail investigation, findings and actions) within five working days of occurrence:
On December 6, 2021, the facility reported that Resident 2's son-in-law had written checks from the resident's personal checking account without the resident's permission. Four of the involved checks were for amounts over $500 dollars and the signatures on the checks appeared to be forged. The facility submitted a PB22, which was reviewed and then rejected by the State Survey Agency, because it lacked the detailed information necessary to process the PB22.
A review of the facility's file maintained in the State Survey Agency Field Office, the facility administration had been contacted by a field office surveyor via email on March 10, 2022, March 21, 2022, and April 7, 2022 to resubmit the completed required abuse investigation, PB22, to include the information that had been omitted from the original submission. On April 19, 2022, an onsite visit was conducted at the facility, and the Field Office representative/surveyor again requested that the completed PB22 be resubmitted with the needed details.
The complete PB22 with all required/necessary information for State Agency completion was not resubmitted to the Field Office, after its original rejection, until May 26, 2022.
The facility reported that Resident 3 had alleged mental abuse by a staff member on the nurse aide registry on January 4, 2022. The allegations included the aide refusing to answer the resident's call bell and making derogatory remarks to her.
A review of the facility file maintained in the State Agency Field Office, revealed that the facility administration had been contacted by a field office surveyor via email on March 10, 2022, March 21, 2022, April 7, 2022 and June 2, 2022, to submit a required abuse investigation, a PB22, as one had never been submitted in response to this allegation. On April 19, 2022, an onsite visit was completed at the facility, and a Field Office representative/surveyor again requested the PB22 be submitted to the State Survey Agency.
A review of the State Agency ERS, revealed a PB22 investigation was not submitted to the Field Office until June 13, 2022. A review of the submitted PB22/investigation on June 22, 2022, revealed that the facility failed to include witness statements and the registry number or date of birth of the accused, which was necessary for processing of the PB22 and confirmation that the facility investigation contained all the components necessary for a complete investigation.
A review of the State Agency ERS completed on June 22, 2022, revealed that the facility submitted a PB22, which contained a witness statement, but did not include the required contact information for the witness. The PB22 still did not contain a date of birth or registry number, necessary to confirm the accused status on the registry. The PB22 was again rejected on June 22, 2022, as remained incomplete as of the time of this survey.
A review of the State agency ERS completed on June 23, 2022, revealed that the facility failed to submit results of the abuse investigations, which contained all elements necessary for completion, for the above instances of alleged resident abuse or neglect to the State Survey Agency within 5 working days of the occurrence. When areas of missing information were identified and the information required was requested by the State Agency, the facility continued to delay submission of this necessary data and failed to submit the completed investigations.
A review of electronic email communication with the facility revealed that on February 2, 2022 the Nursing Home Administrator had notified the Field Office that the facility had been having migration issues with emails, related to another issue. They had expressed no other concerns subsequently and had successfully communicated about other matters after that date with the State Survey Agency field office. There was no indication that the facility notified the field office before the June 2, 2022 email communication, that they had been having difficulty submitting information or requested/completed assistance with submission.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 201.29 (a)(c)(d) Resident Rights
| ||Plan of Correction - To be completed: 07/22/2022|
Despite the inability to properly submit two PB-22's via the EHRS System, both events were fully investigated by the facility leadership at the time of the occurrence and the reporting to the Department of Health occurred as required. Multiple efforts were made to resubmit these PB-22's as requested by the Field Office.
The PB-22 for resident 2 was submitted successfully on 5/26/22, while the PB-22 for resident 3 was successfully submitted on 6/13/22. Admittingly, the facility encountered difficulty with submitting these two PB-22's. All other PB-22's were submitted successfully by the facility leadership.
Moving forward, all PB-22's will be completed and submitted in their entirety within 5 working days.
The NHA and DON have reviewed the required reporting requirements related to this F-tag and will ensure adherence moving forward. The NHA or DON will immediately report concerns, on a consistent basis, to the Field Office.
The NHA will complete a Quality Assessment Performance Improvement (QAPI) project to ensure that all PB-22's are completed and successfully submitted within 5 working days. This will occur until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety/Compliance Meeting and if indicated, corrective action will be taken.