|§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:|
§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.
§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
§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.
Based on staff interview, clinical record review, review of facility policy and procedure, and review of documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an allegation of psychological abuse for one (Resident R2) of two residents reviewed.
Review of facility policy titled, "Resident Abuse", revised on November 2016, revealed "Psychological abuse includes verbal abuse, mental abuse, threats, isolation and any behavior which causes fear in the resident."
Further review of facility abuse policy revealed "All incidents of abuse or suspected abuse will be thoroughly investigated by the facility. The policy further states "The facility will have evidence that all alleged violations are thoroughly investigated."
Review of clinical documentation revealed a Minimum Data Set (MDS) dated December 21, 2020, for Resident (R2) including a Brief Interview for Mental Status (BIMS) with a score of 15, indicating intact cognitive response.
Review of facility documentation revealed a grievance form submitted on December 21, 2020, by Licensed Employee (E1). Report of the incident stated resident reported "she (Resident R2) was reprimanded by her nurse" following a phone call Resident R2 received on December 18, 2020, where she discussed complaints related to her care.
Further review of the grievance form revealed that Licensed Employee (E2) attempted to interview the resident on December 21, 2020, but was unable to complete interview.
Review of Resident R2's clinical documentation revealed the resident was hospitalized from December 21, 2020, until December 23, 2020.
Review of facility documentation revealed that Employee (E2) interviewed Resident R2, and the documentation stated "resident did not want to talk about the incident."
Further review of facility and clinical documentation failed to reveal an investigation was completed.
An interview with the Nursing Home Administrator and the Director of Nursing (DON) on February 16, 2021, at 12:52 p.m. confirmed that the facility did not investigate the allegation of psychological abuse.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 201.29(a)(d) Resident Rights
28 Pa. Code 211.5(f) Clinical Records
| ||Plan of Correction - To be completed: 03/15/2021|
- Resident R2 no longer resides at the facility
- Implementation of investigation checklist to include question of we're all shift staff interviewed for the alleged event, residents, witnesses, and other residents who may of been effected
- Social Services Coord or Designee will educate all staff by 3/15/21 on signs of abuse and reporting
-Social Services or designee will complete monthly audit of grievance binder to ensure checklist is being used appropriately.
-NHA will review all grienves for satisfactory completion before signing off that grievance was resolved effectively.
- Audit tool will be presented to QAPI committee for review and suggestion