§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.
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Observations:
Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that allegations of physical abuse were reported in a timely manner for one of 10 residents reviewed (Resident 2).
Findings include:
The facility's abuse policy, dated December 12, 2023, indicated that it is the facility's policy to investigate all allegations, suspicions, and incidents of abuse. Staff must immediately report all such allegations to the Nursing Home Administrator/Abuse Coordinator. The Nursing Home Administrator/Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. If the event that caused the allegation involves an alleged abuse, it should be reported to the Department of Health immediately, but no later than two hours after the allegation is made.
An annual MDS assessment for Resident 2, dated May 17, 2024, revealed that the resident was sometimes understood, could usually understand others, required substantial or maximum assistance with personal hygiene, was independent with ambulation, and had diagnosis that included dementia.
A nurse's note for Resident 2, dated May 27, 2024, at 7:35 a.m., revealed that the resident had purple bruising noted to the bilateral inner and outer corners of his upper eyelids. A note, dated May 27, 2024, at 1:00 p.m., revealed that upon further investigation it was noted that on May 26, 2024, a housekeeper heard residents yelling and witnessed Resident 2 in Resident 1's room. Resident 1 was observed kicking at Resident 2 and being physically aggressive. Resident 2 did not hit back.
Review of the facility's event report, dated May 27, 2024, at 5:00 p.m., revealed that on May 26, 2024, at 1:30 p.m. the fourth-floor housekeeper heard Resident 1 yelling out. She went to Resident 1's room and observed Resident 2 in the room, with Resident 1 kicking at Resident 2 and being physically aggressive to get him out of his room. Staff were able to separate and redirect both residents at the time.
There was no documented evidence that the physical abuse by Resident 1 toward Resident 2 was documented or reported to the Nursing Home Administrator/Abuse Coordinator or Director of Nursing at the time the incident occurred and no documented evidence that the incident was reported to the Pennsylvania Department of Health within two hours of the occurrence.
Interview with the Director of Nursing on May 31, 2024, at 1:30 p.m. confirmed that the resident-to-resident physical abuse by Resident 1 to Resident 2 occurred on May 26, 2024, and that it was not reported by staff when it occurred and should have been.
Interview with the Nursing Home Administrator on June 6, 2024, at 8:10 p.m. confirmed that staff did not report the allegation of physical abuse by Resident 1 to Resident 2 on May 26, 2024, and administration did not report the allegation of physical abuse to the Department of Health within two hours of the incident occurring per facility policy.
28 Pa. Code 201.14(c) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1) Nursing Services.
Chapter 51.3(f) Notification.
| | Plan of Correction - To be completed: 07/10/2024
1. Event report on resident to resident was reported to the Department of Health via the Event Report System.
2. There were no other outstanding resident to resident altercations during this time.
3. All staff will be re-in serviced by staff development or designee on Department of Health reporting requirements of Abuse via the ERS within 2 hours
4. Audits of abuse event reporting via the ERS system will be audited weekly for four weeks. Then monthly for two months by Director of Nursing/designee. Results will be reviewed at QA meeting for further recommendations and follow-up by Director of Nursing/designee.
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