§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 facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of neglect in a timely manner for one of seven residents reviewed (Resident 3).
Findings include:
The facility's abuse policy, dated March 4, 2024, revealed that all allegations of abuse shall be reported immediately to the charge nurse, Director of Nursing, Nursing Home Administrator, and resident's physician for investigation into the circumstances of the incident. The staff member who discovers the incident, suspected abuse situation, or has the initial knowledge of such incidents will be responsible for immediately notifying his or her supervisor. The supervisor who becomes aware of such incidents must immediately report to the Nursing Home Administrator and Director of Nursing, in person or by telephone.
A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 3, dated February 19, 2025, revealed that the resident was understood, could understand, was cognitively intact, and had diagnoses that included venous insufficiency (poor circulation) and muscle weakness. Resident 3's care plan, dated May 28, 2024, revealed that the resident required staff assistance for daily care needs, including toileting, hygiene, and dressing, and that the resident was encouraged to ring his call bell for assistance.
A statement completed by Housekeeper 1, dated February 21, 2025, revealed that on February 15, 2025, she observed Nurse Aide 2 remove Resident 3's call bell and place it behind him out of his reach. She indicated that she entered the room and gave Resident 3 his call bell back, and Nurse Aide 2 told her not to do that. After Nurse Aide 2 left the room, Housekeeper 1 was still cleaning the resident's room when he rang his call bell. Nurse Aide 2 returned to the resident's room and said, "See, that's why I took his bell off of him."
A statement by Nurse Aide 2, dated February 24, 2025, indicated that she recalled asking Housekeeper 1 why she gave Resident 3 his call bell back. She indicated that she planned to return to his room. She indicated that she did not understand why Housekeeper 1 had to give Resident 3 his call back when she planned to return to the resident's room at some point.
A statement completed by the Director of Nursing on February 21, 2025, revealed that he was notified on February 21, 2025, that on Saturday, February 15, 2025, Housekeeper 1 witnessed Nurse Aide 2 remove Resident 3's call bell from his reach and that she told Housekeeper 1 not to give it back to the resident.
Interview with Resident 3 on March 5, 2025, at 10:44 a.m. revealed that he recalled a staff member that would take his call bell from him from time to time. She would also tell him not to ring his bell so much because she was busy. He stated that he understood that she was busy because there was a lot of people to take care of at supper time, but that he liked to have his call bell where he could reach it. He stated that he could feed himself, but he had to rely on the staff to do everything else for him. He said he could not recall the nurse aide's name, but that it was always the same one that would take the call bell from him. He could not recall the last time he saw her or the last time that she took his call bell from him.
Following the incident on February 15, 2025, Nurse Aide 2 continued to work with Resident 3, as well as other residents on February 16, 18, 19, and 20, 2025. Housekeeper 1 failed to report her observations and concerns of neglect until February 21, 2025. Nurse Aide 2 was suspended from her duties on February 21, 2025, and after the investigation her employment with the facility was terminated. An in-house audit was performed on residents and assessments were completed along with interviews to confirm no other residents were identified. Housekeeper 1 was re-educated regarding abuse, and then quit her position.
Interview with the Nursing Home Administrator on March 5, 2025, at 11:16 a.m. revealed that Housekeeper 1 was newly hired on February 11, 2025, and was educated regarding reporting abuse. She stated that Housekeeper 1 did not report her concerns until February 21, 2025, and that she should have reported them immediately.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 03/30/2025
Resident 3 is alert and oriented and was examined. He did not experience any harm.
Housekeeper 1 was re-educated regarding abuse reporting by the Director of Nursing immediately upon receipt of this allegation on February 21, 2025. Housekeeper 1 is no longer employed by the facility.
Facility staff were re-educated by the Director of Nursing/designees on abuse reporting on 3/5/25.
Audits will be conducted by the Director of Nursing or designee once per week for 4 weeks, and once per month for 2 months to verify staff compliance and understanding of reporting abuse. Audit results will be reviewed by the Quality Assurance Performance Improvement Committee.
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