§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 review of policies, investigative reports, and residents' clinical records, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan and transfer status for one of 10 residents reviewed (Resident 1).
Findings include:
The facility's current policy regarding abuse, neglect and exploitation indicated that neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 9, 2024, revealed that the resident was severely cognitively impaired, required assistance from staff for transfers, and had diagnoses that included dementia. The resident's fall care plan, revised on February 15, 2024, indicated that she was a physical assist of two for transfers. A physical therapy discharge summary for Resident 1, dated February 15, 2024, revealed that on discharge Resident 1 required a physical assist of two for transfers.
A nursing note for Resident 1, dated February 25, 2024, revealed that while being transferred from her wheelchair she pulled her legs up at the knees. Resident 1 had to be placed back in the wheelchair and her right calf caught on the bracket where the foot pedal attaches causing a skin tear. The wound was cleansed, and a sterile dressing was applied.
The facility's investigation determined that Nurse Aide 1 transferred Resident 1 by himself. A witness statement, dated February 25, 2025, indicated that Resident 1 was changed and cleaned in bed. While sitting up in bed she was transferred to her wheelchair. Her legs were tucked up and her calf was cut on the right leg. The nurse was notified and first aid was completed. Resident 1 was harder to transfer when she tucked up.
Education paperwork provided by the facility, dated February 22, 2024, revealed that concerns were reported to the Director of Nursing and Nursing Home Administrator regarding Nurse Aide 1. It was reported that Nurse Aide 1 transferred a resident in a manner that was against their care plan and was not in line with the therapy recommendation. This could be an issue of safety and could cause the resident to have a fall or injury.
A nursing note for Resident 1, dated March 10, 2024, revealed that the skin tear on the right calf reopened and would care was ordered.
Observations of Resident 1 on March 20, 2024, revealed that she was visiting with a family member. She was sitting in her wheelchair, and there was a dressing applied to her right lower leg.
Interview with the Director of Rehab on March 20, 2024, at 3:27 p.m. confirmed that Resident 1 was a moderate assist of two staff for transfers.
Interview with Nurse Aide 1 on March 20, 2024, at 4:45 p.m. confirmed that he transferred Resident 1 by himself because he was not aware that she was a two-person physical assist. The education he received regarding the unsafe transfer with Resident 1 was dated February 22, 2024; however, he confirmed that the form was dated inaccurately.
Interview with the Director of Nursing on March 20, 2024, at 2:55, 3:45, and 4:45 p.m. confirmed that Nurse Aide 1 transferred Resident 1 by himself and that the resident required a two-person physical assist. The Director of Nursing also confirmed that the education was inaccurately dated for February 22, 2024, instead of February 25, 2024.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
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: 04/11/2024
The resident is now being transferred assist of 2 per the care plan. The right calf skin tear is resolve per wound nurse note dated 3/26/2024, orders discontinued, and care plan has been updated. Nurse aide 1 was disciplined and educated on the importance of following the residents care plan.
All resident care plans were reviewed to ensure the proper transfer status was care planned. A system change was implemented. A form was created which will include the residents transfer status that was placed on the inside of the resident's closet door for easy reference and privacy. The therapy team will update the forms as resident transfer status changes. Education was provided to staff on the importance of following the resident scare plan including transfer status. Staff was also educated on the system change.
Therapy will report transfer status changes in daily morning meeting. The NHA/designee will perform audits to ensure the transfer status changes are being changed on the form inside the resident's closet door and the care plans are being updated. This will be an ongoing process. The DON/designee will audit the resident transfer status five times a week for one week, then twice a week for two weeks, and then bi-weekly for two weeks. Audits will be ongoing randomly.
Outcomes of the audits will be presented to the quality assurance process improvement committee for review and recommendations.
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