§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 observation, review of clinical record, facility documentation review, facility policy review, hospital records review, and staff and resident interviews, it was determined that the facility failed to ensure that residents were protected from neglect during provision of care for one of four residents reviewed (Resident 1). The facility staff member failed to verify the resident and transfer status, which resulted in actual harm to Resident 1 who sustained a laceration to the right lower leg, transfer to the hospital, and received 13 sutures to the right lower leg.
Findings Include:
Review of the facility's policy, titled "Abuse Prohibition-Abuse, Neglect, and Misappropriation of Resident's Property", revised June 14, 2023, revealed that "neglect is defined at 483,5 as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person."
Review of Resident 1's clinical record revealed that the Resident was admitted to the facility on October 20, 2023, with diagnoses that included anorexia nervosa (an eating disorder causing people to obsess about weight and what they eat) and failure to thrive (doesn't gain weight normally).
A review of Resident 1's Quarterly Minimum Data Set (MDS - a periodic review of a resident's assessment and care needs), dated May 2, 2024, revealed that Resident 1 needed two persons' physical assistance with staff for transfer to move between surfaces including to and from bed, chair, and wheelchair.
A review of Resident 1's current care plan revealed that Resident 1 had an activity of daily living self-care performance deficit related to weakness. The care plan was revised on June 6, 2024, to reflect Resident 1 transfers via a full mechanical lift. During an interview with the Director of Nursing (DON), she stated that Resident 1 was a 2-person transfer with a rolling walker prior to the revision on June 6, 2024.
Review of Resident 1's physician orders revealed that on October 25, 2023, the physician order was to transfer with assistance of 2-persons and a rolling walker. On June 6, 2024, the physician orders were revised to transfer via mechanical lift. Concluding that, at the time of the incident, the Resident was to be transferred with 2-persons assisting and her rolling walker.
Review of facility reported incident, submitted on June 6, 2024, revealed that "when Resident 1 was being transferred from bed to wheelchair by Employee 1 (Nursing Assistant) she noticed a laceration to the right lower leg when pulling Resident 1 back in wheelchair. Per resident's care plan, resident transfers with 2 assist and rolling walker. It is reported that Employee 1 transferred Resident 1 with 1 assist." The facility substantiated neglect and told the staffing agency that Employee 1 is a Do Not Return to facility.
Review of Resident 1's nursing notes dated June 4, 2023, at 6:04 AM, stated that she was transferred to the hospital emergency department for right leg shin wound, physician and Resident Representative were made aware.
A review of Employee 1's telephone statement obtained by the Nursing Home Administrator on June 5, 2024, revealed Resident 1 sustained a skin tear when re-positioning her in the wheelchair during a transfer. Employee 1 stated, "Resident 1 pushed up on the wheelchair via arm rest and I pulled, hitting her leg on the piece of her wheelchair where the leg rest go. I reported the incident to the Registered Nurse immediately." Employee 1 stated that she was given instruction to weigh a resident, but went into the wrong room and proceeded to transfer Resident 1 out of bed independently to obtain a weight. Resident 1 was not supposed to be weighed that shift and had no orders to be out of bed to be weighed.
A review of Employee 1's personnel file on June 10, 2024, revealed her most recent completion of training on abuse, neglect, and misappropriation was on July 7, 2023.
During an interview with Resident 1 on June 10, 2024, at approximately 10:15 AM, she was asked if she could recall what happened when she injured her leg she replied, "yes." Resident 1 added, "I asked the nurse why she was getting me out of bed to be weighed and she told me, that's how we weigh people." Resident 1 also confirmed there was only one staff person who assisted her out of bed. Resident 1 stated, "when she pulled me back in the wheelchair my leg was caught by the metal piece on the wheelchair."
A written statement by Employee 2 (LPN-Licensed Practical Nurse) on June 4, 2024, revealed that she overheard the LPN charge nurse inform Employee 1 that the transfer status for all residents is on the back of their closet door. She also stated that Resident 1 told Employee 2 and the EMT that she sustained the skin tear during the transfer to her wheelchair from her bed.
A review of the written statement by Employee 3 (Nurse Aide) on June 4, 2024, stated that Employee 1 was told to wash and dress Resident 1 only and "NOT to get her out of bed". The statement also said that Employee 3 reviewed with Employee 1 the residents who needed washed up and dressed and not to get out of bed; and also the residents who needed weighed. During a phone interview with Employee 3 on June 10, 2024, at 10:30 AM, it was confirmed that Employee 1 was told by Employee 3 to wash and dress Resident 1 only, and not to get her out of bed.
A review of hospital records for Resident 1 dated June 4, 2024, stated, "Resident 1 sustained an L-shaped laceration to the lateral aspect of the right lower extremity, there is a flap of skin evident, adipose tissue exposed, no muscle belly exposure (fleshy part of the skeletal muscle); L-shape approximately 7 cm x 6 cm (total laceration 13 cm). Resident 1 received 13 sutures to repair the laceration. A non-adherent (non-stick) dressing and antibiotic ointment was applied."
An interview with the DON on June 10, 2024, at 11:00 AM, confirmed that the facility failed to follow the transfer status and provide 2-person assistance during the transfer for Resident 1.
The facility failed to ensure a Resident was protected from neglect during the provision of care by transferring the Resident from the bed to the wheelchair with the assistance of only one staff. Employee 1 neglected to follow the transfer status and failed to confirm the resident care needs. This failure resulted in actual harm to Resident 1 who sustained a laceration, transfer to the hospital, and required 13 sutures.
28 Pa Code 211.10(d) Patient care policies
28 Pa Code 211.12 (c) Nursing Services
28 Pa Code 211.12 (d)(3)(5) Nursing Services
| | Plan of Correction - To be completed: 06/20/2024
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law.
1. The resident was treated and returned to the facility. She has reported that she is comfortable and free from pain. Her plan of care has been updated to reflect her treatment orders. The facility notified the CNA's agency of the event and the aide was placed on a do not return status.
2. A base line audit was completed for other residents on the assignment and indicates that all other transfers were completed appropriately.
3. The Director of Nursing or designee will complete education to clinical employees on the transfer/lift policy, proper procedure for resident identification, validation of transfer status within the point of care platform and or the resident Kardex to ensure that residents are properly identified, and transfer status is confirmed prior to transfer occurring. In addition, this education will be added to the agency orientation checklist and current agency staff will also sign off on education.
4. The Director of Nursing or designee will also provide education to the clinical staff on the definition and examples of neglect as it relates to following a resident's plan of care.
5. An audit will be conducted by the Director of Nursing /designee to ensure that residents are properly identified and who are assist of 2 with transfers are properly transferred as their plan of care and orders indicate. Audits will be completed for 7 days, 10 residents per day (for 1-week) then 5 days a week( for 1 week) then, 3 days a week(for 1 week) then 1 day a week( for 2 months). Each daily audit will include no less then 10 residents. Results of the audit will be taken to QAPI for review of findings and further interventions if warranted.
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