|§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 review of clinical records, facility documentation, facility policies and procedures, and interviews with staff, it was determined that the facility failed to thoroughly investigate an incident related to a fall, for one of 43 residents reviewed. (Resident R28)
Review of Resident R28's clinical record revealed that the resident was admitted on February 10, 2015, with diagnoses including Dementia without behavioral disturbance (Dementia is a general term to describe symptoms of impairment in memory, communication, and thinking), and age-related Osteoporosis (a condition in which bones become weak and brittle).
Review of nurse's progress note, dated December 27, 2019, at 6:00 p.m., stated that, "nurse was called to second floor C-Hall bathroom due to resident falling. Resident was observed sitting on the toilet, following assessment by nurse. Emergency response was called due to resident hitting her head and inability to move right upper extremity. Vital signs were stable, and resident does not appear to be in any distress. Message was sent to doctor, and POA (Power of Attorney) was notified about incident. Resident was picked up at 6:30 p.m." The nurse's progress note further stated that the resident was being admitted for fracture of right ulna and radius (the breakage of one of the two or both the bones of the forearm right near wrist joint), right forehead hematoma, and possible syncopal (fainting) episode after fall.
Review of hospital documentation revealed a physician's note dated December 31, 2019, which noted, "unclear if the patient actually passed out .... I think it is less likely that a cardiac arrythmia or bradycardia contributed much to the fall. It could have been micturition syncope (the human phenomenon of fainting shortly after or during urination), as she was using the toilet just prior to the fall".
On January 16, 2020, approximately at 10:50 a.m., reviewed the facility documentation named 'Event Data Collection Worksheet', dated December 28, 2019, related to the fall incident of Resident R28, which indicated "CNA (nursing assistant) had resident on toilet in C-hall shower room and went to get soap from other side of room, and resident stood up and attempted to ambulate self and fell. Was found sitting on floor by trash can in bath room".
Further review of the fall investigation dated December 27, 2019, identified the name of the nursing assistant, Employee, E4. under the paragraph named "describe incident in full detail including events that led up to the incident." The nursing assistant, E4, stated that, "I put her on the toilet, went to get soap and heard her fall."
Interview conducted on January 16, 2020, approximately at 2:50 p.m., with nursing assistant, Employee E4, revealed that she was unable to describe any additional details other than what she had already stated in the 'Event Data Collection Worksheet' dated December 28, 2019.
Interview with the Director of Nursing on January 16, 2020, approximately at 2:57 p.m., confirmed that there was no documentation to complete a thorough investigation, to rule out potential resident abuse or neglect, for Resident R 28.
The facility failed to conduct a complete and thorough investigation to rule out potential resident abuse or neglect for one resident.
| ||Plan of Correction - To be completed: 03/09/2020|
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
Documentation regarding the accident involving resident R 28 was reviewed to ensure all required pertinent data was obtained to complete the investigation and any appropriate actions will be taken.
All facility investigations of abuse, neglect, exploitation or mistreatment will include but will not be limited to conducting observations of the alleged victim, conduction interviews with the alleged victim, alleged perpetrator, witnesses and others as appropriate, conducting a record review for pertinent information.
Education will be provided on required data to all staff that are responsible for completing an investigation.
Audits will be completed by the DON/ Designee on all incidents and accident reports X 6 weeks to ensure proper steps are taken when abuse, neglect, exploitation or mistreatment is alleged. Deficient findings from the audit will be reported to QAPI committee for review and appropriate action.