§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.
§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
§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.
|
Observations:
Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse or neglect as the cause of a bruise for two of four residents reviewed (Residents 3 and 4).
Findings include:
The facility's policy regarding resident abuse/neglect, dated December 16, 2025, revealed that possible indicators of abuse include but are not limited to (2) physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. An investigation is warranted when suspicion of abuse , neglect or exploitation, or reports of neglect or exploitation occur. Written procedures for investigation include identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and any others who may have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred and the extent and cause; and providing complete and thorough documentation of the investigation.
The facility's policy regarding incidents and accidents, dated December 16, 2025, revealed that the purpose of incident reporting can include assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve management of resident care; and conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement to avoid further occurrences.
A quarterly MDS assessment for Resident 3, dated February 11, 2026, revealed that the resident had severe cognitive impairment, was dependent on staff for most daily care needs, and had diagnosis that included heart failure and anxiety.
A nurse's note for Resident 3, dated April 15, 2026, at 4:46 a.m. revealed that a nurse aide reported that the resident had a bruise on her left forearm. The nurse observed a dark purple bruise four centimeters (cm) by two cm on the resident's left forearm. The Registered Nurse supervisor was notified and came to assess. The resident did not know how the bruise happened and had no complaints of pain or discomfort at the time.
A facility injury investigation, dated April 14, 2026, at 10:00 p.m. revealed that Resident 3 had a bruise on her left forearm. The nurse observed a dark purple bruise four centimeters (cm) by two cm on the resident's left forearm. The Registered Nurse supervisor was notified and came to assess. The resident did not know how the bruise happened and had no complaints of pain or discomfort at the time. There was no documented evidence that a thorough investigation was completed to identify the root cause of the bruise or rule out abuse or neglect.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, revealed that the resident was usually understood and sometimes able to understand others, required assistance form staff for daily care needs, and had diagnosis that included dementia.
A nurse's note for Resident 4, dated March 29, 2026, at 6:23 p.m. revealed that the resident's son called and reported observing a bruise on the resident's right forearm during his visit yesterday. The son inquired if there was any prior documentation regarding this bruise. This nurse informed him that there was currently no documentation on that bruise but was reassured that a full assessment would be completed to assess for any additional bruises. Bruise to right forearm measured approximately six cm by nine cm and was yellow and green in color. Additionally, there were two small bluish-purple bruises noted to residents left shin. No other bruising was noted at the time. Resident was an unreliable historian and unable to provide accurate information regarding the origin. The Registered Nurse and the Assistant Director of Nursing were made aware, and a message was left for the resident's son regarding the assessment findings.
Review of a grievance filed for Resident 4 dated March 30, 2026, revealed that the resident's son had noticed a fist sized bruise on the resident's right arm and that the facility would interview staff that provided care, and the resident.
A facility injury investigation, dated March 29, 2026, at 1:15 p.m. revealed that resident's son called and reported observing a bruise on the residents right forearm the day prior during his visit. This nurse asked the resident to see her arm and observed a yellow/green bruise measuring approximately six cm by nine cm. When asked if she remembered what happened the resident stated, "three girls held me down". The resident's son expressed that he knows his mom is unable to give a reliable description because of her diagnosis, but she did tell him it was caused by a girl the day prior when he asked. Interview with the resident revealed that she stated "I am 100 years old, and my memory is not very good. But I was in a place and there was some girls cleaning up and they tried to get me to go somewhere and they pulled on me. I think that is where that came from. I have had it for weeks. My neck also hurts and maybe it is from that too." Resident did not have any other bruises on her arm or her neck. She stated "well, then maybe I made that up too?" "I don't really know". There was no documented evidence that staff were interviewed to identify if any abuse/neglect may have occurred.
A nurse's note for Resident 4, dated April 28, 2026, at 11:14 a.m. revealed that an aide notified the nurse that there was bruising to the resident bilateral upper extremities and her right lower extremity. The resident was asked if she bumped into anything and she reported to this nurse "not that she was aware of." She was asked by this nurse if anyone had grabbed her, and the resident reported "Not as far as I know." A registered nurse assessment, vital signs were stable, resident had no pain or discomfort, skin was intact, and doctor and son were notified.
A facility injury investigation, dated April 28, 2026, at 11:04 a.m. revealed that a nurse aide notified the nurse that there was bruising to bilateral upper extremities and her right lower extremity. The resident was asked if she bumped into anything and she reported to this nurse "not that she was aware of." She was asked by this nurse if anyone had grabbed her and the resident reported "Not as far as I know.". There was no documented evidence that a thorough investigation was completed to identify the root cause of the bruise or to rule out abuse/neglect.
Interview with the Director of Nursing on May 19, 2026, at 3:45 p.m. confirmed that a thorough investigation was not completed to attempt to identify the root cause of a bruise or rule out abuse/neglect related to the bruises on Residents 3 and 4 on the above-mentioned dates.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 07/10/2026
The preparation and/or execution of the plan of correction does not constitute admission of agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies.
The Director of Nursing or designee will conduct an audit by 6/12/2026 of the facility's risk management/incident reports from May 12, 2026 until June 11, 2026 to ensure that no other bruises of unknown origin were present on facility residents.
An in-service/education will be conducted by June 18, 2026 by the Director of Nursing or designee with certified nursing assistants, licensed practical nurses and registered nurses regarding the facility's abuse and neglect policy and reporting procedures.
The Director of Nursing or designee will audit all new facility risk management/incident reports beginning after initial whole house audit to ensure bruises of unknown origin are thoroughly investigated for potential abuse weekly x2 and then monthly x2.
This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.
|
|
