§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 a review of clinical records, the facility's abuse prohibition policy, and select facility incident investigations, and staff interview, it was determined that the facility neglected to provide the care and services necessary to prevent physical injury or harm for two out of five residents sampled (Residents CR2 and 26).
Findings include:
A review of the facility's Investigation of Allegations of Abuse, Neglect, or Misappropriation of Resident Policy last reviewed May 2023, indicated as last reviewed by the facility on November 1, 2023, revealed that the facility will provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and to promote or maintain the resident at their highest level of well-being. Allegations of abuse, defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish, as well as neglect, financial exploitation or misappropriation of resident property will thoroughly be investigated by the facility. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes, but is not limited to: failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment, and care including but not limited to: nutrition, medication, therapies, and activities of daily living.
Clinical record review revealed that Resident CR2 was admitted to the facility on February 8, 2024, with diagnoses which included Parkinson's disease (disease of the central nervous system that affects movement, often including tremors).
A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 14, 2024 indicated that Resident CR2 had severe cognitive impairment with a BIMS score of 07 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment).
Review of Resident CR2's care plan, initially dated February 8, 2024, indicated that the resident was at a risk for falls with planned interventions, which included high-low bed maintain in low position when in bed.
A nurses note dated February 26, 2024, indicated that Resident CR2 was found on the floor. Resident sustained an open hematoma to left forehead with moderate amount of bleeding. The physician was notified. The resident was transferred to the emergency room.
A nurses note dated February 26, 2024, at 5:00 PM indicated that Resident CR2 returned to the facility with a small laceration to right forehead. Neuro checks at resident's baseline.
Review of a facility incident report dated February 26, 2024, at 10:45 AM revealed that Resident CR2 was found lying on his right side on the floor between the beds of the resident's room. Prior to the incident Resident CR2 was found self-transferring into bed after breakfast.
A statement by Employee 2 (LPN) noted that the resident was last seen in bed after breakfast. Employee 2 (LPN) stated that she responded to the resident's chair alarm and found him in bed. Employee 2 stated that prior to the fall the resident's call bell was in reach and proper footwear was in place.
The investigation determined that Employee 2 (LPN) however, did not put the resident's bed in the lowest position at the time of the fall as per the resident's care plan.
Interview with the director of nursing on May 21, 2024, at 2:00 PM confirmed that prior to the resident's fall Employee 2 neglected to implement the planned intervention to ensure that Resident CR2's bed was maintained in the lowest position to prevent injury.
Clinical record review revealed that Resident 26 was admitted to the facility on March 7, 2024, with diagnoses, which include diabetes and peripheral vascular disease.
A review of an admission Minimum Data Set assessment dated March 13, 2024, indicated that Resident 26 was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognitively intact).
Review of a nurses note dated April 10, 2024, at 2:00 PM revealed that the resident's wheelchair fell backwards during transport in the wheelchair van on the way to a medical appointment. The resident struck his head on the floor of the van. 911 was called to transport the resident to the emergency room for evaluation.
A nurses note dated April 10, 2024, at 5:00 PM noted that the resident returned to the facility from the emergency room. A 3 cm x 3 cm soft protrusion was present in the mid occipital (back) region of the resident's head.
Review of a facility investigation dated April 10, 2024, concluded that while on route to an appointment, the tie downs attached to the front of the wheelchair became unattached, causing the resident's wheelchair to flip backwards, thus causing the resident to hit the back of his head on the floor of the van. Emergency medical services was called to transport the resident to the emergency room. The resident did not have any loss of consciousness. The investigation concluded that Employee 3 (van driver) failed to secure the front tie downs properly on the wheelchair.
Interview with the director of nursing on May 21, 2024, at 2:30 PM confirmed that the Employee 3 neglected to provide the necessary services to maintain Resident 26 safety during transport to an appointment.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident Rights
28 Pa. Code 211.12 (d)(5) Nursing Services
| | Plan of Correction - To be completed: 06/26/2024
1. Resident 27 and Resident CR2 have been discharged
2. Current residents shall have bed in lowest position while resident in bed unless careplanned otherwise.
Resident safety shall be maintained during transport to and from appointments in van.
3. Nursing personnel have been re-educated to ensure bed is placed in lowest position when any resident is transferred to bed; unless care planned otherwise.
Van Drivers shall be re-educated on the driving protocol and the importance of adhering/securing resident in the van. All EEI Van drivers shall complete a return demonstration of fastening/securing tie down straps, seatbelts. Additionally, transport aides/ancillary aides will complete a secondary check prior to resident going to/from appointment to observe that tie-down straps are secured to wheelchair properly and resident secured.
4. IDT/Nursing personnel shall conduct audits on bed height to ensure in the lowest position when resident is in bed.
- Driver/designee shall complete a wheelchair transport checklist to ensure wheelchair is secured and fastened for each resident.
5. Results of audits will be brought to QA for review and recommendations
6. Corrective Action Date: June 26, 2024
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