§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, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of eight residents reviewed (Resident 6).
Findings include:
The facility's abuse policy, dated September 26, 2024, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. An investigation would begin immediately and all applicable local and state agencies would be notified in accordance with the procedures in this policy.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 12, 2024, revealed that the resident was understood and could usually understand others, was dependent on staff for transfers, had no behaviors, and had a diagnosis of dementia.
A nursing note for Resident 6, dated March 12, 2025, at 12:22 p.m., revealed that the Director of Nursing was notified of an allegation of neglect/abuse. A nurse aide moved the call bell from a resident's reach over the weekend and refused to get her out of bed. The facility's investigation, dated March 12, 2025, revealed that Nurse Aide 1 removed Resident 6's call bell and refused to get the resident out of bed.
A witness statement by Licensed Practical Nurse (LPN) 2, signed and undated, regarding the incident of March 9, 2025, revealed that Nurse Aide 1 reported to her that Resident 6 was not getting out of bed because she had "played" in her bowel movement after Nurse Aide 1 washed her. Resident 6 rang the call light multiple times asking to get out of bed. During the dinner tray pass, Resident 6 was hitting her remote off the table and LPN 2 heard Nurse Aide 1 say "stop hitting your remote off the table or I will move your table too." Resident 6's call light was noted to be draped over the night stand. Resident 6 said, "I don't have my call bell, they moved it."
A witness statement by Nurse Aide 3, dated March 11, 2025, revealed that she was not aware that Resident 6's call bell was out of reach and denied involvement with it being moved.
A witness statement by Nurse Aide 1, dated March 13, 2025, revealed that she had worked the past Saturday and Sunday. Resident 6 started yelling that she wanted up in the middle of an emergency. She revealed that Nurse Aide 3 removed Resident 6's call bell on Saturday and when Resident 6 wanted to get out of bed on Sunday Nurse Aide 3 said the resident was not getting out of bed.
A witness statement from Registered Nurse 4, dated March 14, 2025, revealed that Nurse Aides 1 and 3 informed her that they moved the call bell away from Resident 6 so she could not reach it and bother them because they were too busy to deal with her that day.
Interview with the Nursing Home Administrator on May 18, 2025, at 4:30 p.m. confirmed that Nurse Aides 1 and 3 were both assigned to Resident 6's hall and accused each other of removing the call bell. Resident 6's call bell was removed and she was not allowed out of bed. The investigation determined that Nurse Aide 1 removed the call bell, but Nurse Aide 3 was aware and Registered Nurse 4 was aware of the incident but did not report it timely per the abuse policy.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.
28 Pa. Code 211.12 (d)(5) Nursing Services.
| | Plan of Correction - To be completed: 06/27/2025
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the survey ended on May 28, 2025.
1. Actions taken for the situation identified:
The facility cannot retroactively address these situations. Nurse Aides 1 and 3 were suspended pending investigation, and their employment at the facility was terminated. Registered Nurse 4 was re-educated on the facility's policy for reporting abuse and neglect allegations. Resident 6 was interviewed and did not recall the situation. A head-to-toe assessment was completed, an event report was submitted to the Department of Health, and Adult Protective Services was notified.
2. How the facility will act to protect residents in similar situations:
The Director of Nursing/designee interviewed capable residents to ensure there were no concerns with care and services and licensed nurses completed skin assessments on incapable residents to ensure no concerns related to lack of care.
3. System changes and measures to be taken:
The Nursing Home Administrator/designee re-educated current staff on the abuse policy and procedure, including timely reporting of abuse and neglect allegations.
4. Monitoring mechanisms to assure compliance:
To monitor and maintain compliance, the Director of Nursing/Designee will interview 5 capable residents weekly for 4 weeks, then monthly for 2 months regarding abuse and neglect concerns. The Director of Nursing/designee will also complete head-to-toe assessments of 5 incapable residents weekly for 4 weeks, then monthly for 2 months, to identify signs of abuse or neglect. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings for additional recommendations as necessary, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards.
5. Date Corrective Action will be completed:
Substantial compliance is expected by June 27, 2025.
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