§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
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Observations:
Based on interviews with staff, review of clinical records, facility policies and facility documentation, it was determined the facility failed to implement interventions to assure one resident (Resident R3) was free from physical abuse resulting in actual harm to Resident R3 who was struck by Resident R4 in the face with a leg rest, and sustained a chipped tooth for one of 10 resident records reviewed. (Resident R3 and Resident R4)
Findings include:
Review of facility policy titled, "Abuse" revised December 13, 2024, revealed, "each resident will be free from abuse" including "verbal, mental, sexual, or physical abuse." Further review indicated, "residents will be protected from abuse, neglect, and harm while they are residing at the facility" and facility will educate staff in techniques to protect all parties.
Review of Resident R3's clinical record revealed the resident was admitted on January 22, 2025, with diagnoses including Cervical Disc Disorder, muscle weakness, difficulty walking, cognitive communication deficit, Atherosclerosis (coronary artery bypass graft), and Arterial Fibrillation (irregular rapid heart rate).
Review of Resident R3's admission Minimum Data Set (MDS is an assessment of resident's care needs) dated January 28, 2025, revealed Resident R3 was cognitively intact, required maximal assistance with lower body dressing, and used a manual wheelchair for mobility.
Review of Resident R3's care plan, initiated on January 22, 2025, revealed Resident R3 has an ADL (activity of daily living) self-care performance deficit related to muscle weakness, difficulty walking, and muscle wasting and atrophy (reduce muscle mass). Further review of Resident R3's care plan revealed the resident had oral/dental problems and was a smoker.
Review of Resident R4's clinical record revealed Resident R4 was admitted to the facility on August 14, 2024, with diagnoses including cognitive communication deficit, muscle weakness, Rhabdomyolysis (breakdown of skeletal muscle), Bipolar Disorder (condition in which a person has periods of depression of being extremely happy), and Depression (major loss of interest in pleasurable activities).
Review of Resident R4's quarterly MDS assessment dated February 7, 2025, revealed Resident R4 was cognitively intact and used a manual wheelchair for mobility.
Review of Resident R4's care plan initiated on August 16, 2024, revealed Resident R4 had a behavior problem related to insomnia, depression, anxiety. Continued review of Resident R4's care plan revealed a single intervention, "administer medications as ordered. Monitor for side effects and effectiveness."
Review of Resident R3's clinical records including a Social Services note, dated March 24, 2025 revealed, "a violent incident occurred outside in the smoking area. Resident was hit with leg rest from a wheelchair by another resident" and "Resident R3 was struck resulting in the loss of one tooth."
Review of facility documentation titled, "Injury Report," dated March 24, 2025, revealed Resident R3 had a chipped tooth "inside of mouth."
Interview conducted on April 2, 2025, at 9:55 a.m., with the Activity Aides, Employee E6, and Employee E5, who were supervising residents during the smoke break on March 24, 2025, approximately 1:30 p.m. revealed Employee E5 and Employee E6 announced to the residents, the facility staff would no longer provide cigarettes to the residents. Resident R4 responded with verbal aggression using foul language toward Employee E5 and Employee E6.
Continued interview revealed when Resident R3 intervened in an effort to stop Resident R4 expressing foul language towards the activity aides, [Resident R4] "got up with the leg rest in [his/her] hand and started chasing me (Employee E5), attempting to hit me. When [Resident R3] stood up from (his/her) wheelchair to defend (himself/herself), [Resident R4] swung at [Resident R3] in the face with the leg rest." Continued interview revealed Resident R3 dropped back into the wheelchair after the hit and Resident R4 tackled Resident R3 in [his/her] wheelchair and continued to punch (him/her) for approximately 15 seconds.
During the interview, Activity Aides, Employee E5 and E6, revealed Resident R4 portrayed verbal aggression in the past with profanity towards staff during smoke breaks.
During the Interview with Nurse Aide, Employee E11, conducted on April 2, 2025, Employee E11 stated, "Resident R3 threatened to beat up [his/her] roommate" because [his/her] television was loud, "and now [his/her] roommate won't watch TV anymore."
Interview with Nurse Aide, Employee E10, conducted on April 2, 2025, at 11:22 a.m. revealed that last month she heard Resident R4 shout at the roommate, "I will beat you up."
The facility failed to implement interventions to assure Resident R3 was free from physical abuse resulting in actual harm to Resident R3 who was struck in the face with a leg rest and sustained a chipped tooth.
28 Pa. Code 211.10(c)(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 04/25/2025
Step 1
The facility implemented interventions to ensure that resident R3 was safe, free from physical abuse, and was protected from harm while in the facility. The facility implemented interventions to ensure that resident R4 was properly assessed, monitored, and supported to prevent harm to resident R3 or other residents
Step 2
A facility-wide audit was conducted to identify other residents with a known history of physical and verbal aggressive behavior that could potentially cause harm to others. All AAOX3 residents were interviewed, and incident reports from the past 30 days were reviewed to identify any other resident-to-resident abuse incidents. Care plans for all identified residents were reviewed to ensure appropriate interventions and measures were in place to prevent harm to others.
Step3
Facility-wide education was completed on abuse prevention, reporting changes in residents' conditions and behaviors, and de-escalation techniques for managing residents with the potential to cause harm.
Step 4
Residents with documented behaviors will be audited weekly x 4 weeks to ensure interventions and care plans are in place. Results of auditing will be reviewed during QAPI meeting to determine further need for ongoing auditing.
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