§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 a review of clinical records, information submitted by the facility and the facility's abuse prohibition policy and staff interviews, it was revealed the facility failed to timely report multiple instances of verbal and mental abuse perpetrated by one resident out of 10 sampled (Resident A1) to the State Survey Agency and local Area Agency on Aging.
Findings include:
A review of the facility's abuse prohibition policy, dated as reviewed by the facility May 1, 2024 revealed revealed that residents residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance to describe residents, regardless of their age, ability to comprehend or disability.
According to long term care regulatory requirements under Freedom from Abuse, Neglect, and Exploitation Mental and Verbal Abuse are defined as:
Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.
Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.
Examples of mental and verbal abuse include, but are not limited to:
o Harassing a resident;
o Mocking, insulting, ridiculing;
o Yelling or hovering over a resident, with the intent to intimidate;
o Threatening residents, including but limited to, depriving a resident of care or withholding a
resident from contact with family and friends; and
o Isolating a resident from social interaction or activities.
Review of Resident A1's clinical record revealed admission to the facility on May 27, 2024, with diagnoses, which included Alzheimer's disease, adjustment disorder with anxiety, and major depression. The resident was significantly cognitively impaired with a BIMS (Brief Interview for Mental Status a tool to assess cognitive function) score of 2.
Resident A1's care plan, initiated May 27, 2024, identified that the resident had impaired cognitive function related to Alzheimer disease as evidenced by, confusion, long and short term memory problem and poor safety awareness. Planned interventions were to administer medication as per physician orders, allow time for the resident to respond, approach in a calm manner, and to provide activities.
The resident's care plan did not identify that Resident A1 displayed any physically or verbally abusive behaviors towards other residents and staff.
A review of clinical record documention dated June 8, 2024 at 10:38 AM, revealed that Resident A1 displayed behaviors during this shift of nursing duty. The resident was making sexually inappropriate comments to staff. A nurses note dated June 18, 2024 at 2:23 PM, revealed that the resident continue to make sexually inappropriate comments towards staff.
A nursing note dated June 19, 2024 at 11:37 AM revealed that a nurse aide informed the nurse that the resident made inappropriate sexual comments, as well as derogatory comments regarding a nurse aide's ethnicity, while these nurse aides were showering the resident on June 18, 2024.
In response to these inappropriate behaviors, a psychiatric nurse practitioner ordered June 18, 2024, to start Buspirone 5 mg PO (anti-anxiety medication) as needed every 8 hours for anxiety x 14 days
Nursing documentation dated June 20, 2024 at 6:29 PM and June 21, 2024 at 2:58 PM revealed that the resident continued to make inappropriate sexual comments towards staff and had inappropriately touched a therapist and a nurse. Redirection was noted to be unsuccessful and the resident became agitated with redirecting. The resident's inappropriate sexual comments as well as derogatory comments, such as calling nursing staff a "b*tch, continued to occur according to nursing documentation dated June 24, 20240 at 8:13 AM and June 24, 2024 at 2:26 PM. Staff reminded the resident that this inappropriate conversation cannot happen as other residents appear to be agitated by Resident A1's comments. Resident A1 was also interjecting himself into the conversation another resident was having, agitating that resident. Resident A1 asked another resident "what the hell is wrong with your hands?" (referencing the physical appearance of the resident's hands) Staff asked Resident A1 not bother this other resident, but he continued to do so. The nurse then removed the other resident from area due to Resident A1 continuing to ridicule the resident's physical condition.
A nursing note June 24, 2024 at 2:47 PM noted that Resident A1 was continuing to agitate another male resident, pulling the resident's chair alarm from his wheelchair causing it to sound the alarm. Upon staff arrival, Resident A1 accused the nurse of "stealing my toy. Resident A1 refused to given alarm back to the nurse or any other staff stating "I had two of them." The nurse also advised the resident to stop reaching for another female resident's arm, which agitated Resident A1. Resident A1 then pursued another female resident and reached out stroking her arm, and the female resident became agitated.
A nursing note June 28, 2024 at 1:37 PM, indicated that the psychiatric nurse practitioner wrote an order, in response to the resident's recent behavior, for depakote ( A seizure medication sometimes used for behavior control) 125 mg daily BID for dementia with behaviors.
Nursing noted on July 3, 2024 11:00 A.M that Resident A1 continued to make lewd sexual comments to a female resident and attempts to redirect Resident A1 were unsuccessful.
Nursing noted on July 3, 2024, at 1:40 PM that psych services saw the resident and increased the resident's buspirone to 10 mg TID (three times a day).
A nursing note July 3,2024 11:24 P.M. revealed that Resident A1 threatened Resident A2, stating "Wait till I get you alone later. The things I'm going to do to you." Resident A2 became fearful and started crying at which point the police were called to intervene due to Resident A1's physical aggression, assault and verbal/sexual remarks, comments and threats toward multiple staff at this time.
A nurse' note dated July 3, 2024, at 11:43 PM Resident A1 smiled, winked and then waved at Resident A2 who was seated in her wheelchair in front of nurses station. He then yelled out to her stating, "I'm looking forward to seeing you later when no-one is around." Winking again.
Resident A2 began to cry, shake and tremble. She was immediately taken behind nurses station and other staff attempted to intervene while Resident A1 continued to advance down hallway in Resident A2's direction after stopping to curse, yell out loud and threaten the supervisor and the nurse once again for asking him to "please do not come down this hallway. You are making this resident (Resident A2) scared and very uncomfortable." Several staff members attempted to redirect him without success and began to yell, and threaten staff and the police and emergency services/transport were called.
A review of the clinical record revealed that Resident A2 was admitted to the facility on July 21, 2023, with diagnoses to include orthostatic hypotension. A quarterly MDS assessment dated April 15, 2024, indicated that she was moderately cognitively impaired with a BIMs score of 11 (a score of 8 to 12 indicated moderate, cognitive impairment).
A review of Resident A2's clinical record conducted during the survey ending July 21, 2024, revealed no reference to the above incident of verbal and mental abuse and the resident's emotional distress. There was no documented evidence that the facility had provided therapeutic psychosocial interventions to Resident A2 to address the psychosocial harm suffered by the resident as the result of being verbally and mentally abused by Resident A1.
During an interview conducted on July 21, 2024, at approximately 12 PM, Resident A2 stated that she did not want to discuss Resident A1 with this surveyor, only stating that she did not want him near her.
A nursing note dated July 3, 2024, at 11:48 PM revealed that local police and EMS (emergency medical services) arrived at the facility and removed Resident A1 from the facility. The resident returned to the facility July 4, 2024, at 4:31 AM
A nursing note dated July 7, 2024 at 10:18 AM revealed that Resident A1 continued to display inappropriate sexual behaviors, despite re-direction attempts. Resident A1 became agitated with re-direction. He sat across the hall from a female resident stating "the things I would do to you." Staff again attempted to redirect Resident A1 with with no effect noted. Resident A1 then went and sat in the doorway of another resident's room, taunting the other resident by shouting at her causing her to become distressed and needing to be consoled. Resident A1 then began reaching towards a female resident's arm, and told staff "You can't tell me not to touch her."
At the time of the survey ending July 21, 2024, the facility was unable to identify these female residents.
A nursing note dated July 7, 2024 at 6:42 PM revealed that due to the resident's behaviors, and the risk to the safety of staff and other residents, he was sent to emergency room for evaluation and behaviors and will be placed on one on one upon return. The resident was transferred to the hospital at 7:52 PM and returned to the facility on July 10, 2024, at 6:47 P.M.
A nursing note dated July 13, 2024 at 2:07 PM revealed that staff removed Resident A1 from the activity room because he initiated an argument with another resident, which was witnessed by several witnesses within the activity room.
A nursing note dated July 13,2024 3:00 PM revealed that Resident A1 was overheard asking another resident, the age of the female resident's daughter, stating "well if she needs a man I can be your son-in-law." Staff asked Resident A 1 to please keep conversation appropriate as the female resident did not seem to welcome this conversation
A nursing note dated July 13, 2024, at 3:21 PM revealed that nursing responded to the sound of a female resident shouting. Nursing noted that the female resident shouted at Resident A1 "You're a pain in the a*s you know that. You just won't shut up." Another female resident shouted to Resident A1 "oh no buddy you, have the wrong one." Both (unidentified) female residents reported to nursing staff that Resident A1 will not leave them alone nor do they like his conversation. Resident A1 stated to one female resident "I'm keeping my eye on you so you know." The female resident stated "I really don't give a sh*t what you do." The RN and another nurse attempted to return Resident A1 to his room however he has refused. Nursing noted "resident remains under close supervision by this nurse due to complaints of female residents near by and \ refusing to leave area."
A nursing note dated July 13, 2024, at 3:43 P.M. revealed that Resident A1 was at the nurse's station and began to self-transfer. Another female resident in the area, who was ambulatory told Resident A1 to "sit before you fall." Resident A1 told the female resident "well come fix my pants, baby, that's what you're supposed to do."
A nursing note dated July 15, 2024 at 1:59 PM revealed that Resident A1 was insulting other female residents this morning regarding their appearances, such as hairstyle. Resident A1 was attempting to enter other residents' rooms and when redirected jumps up defensively and becomes aggressive with staff.
A nursing note dated July 17, 2024, at 2:19 P.M. revealed that Resident A1 with was asking female resident to remove her panties and making derogatory racial comments to another resident.
A nursing note dated July 17, 2024, at 3:51 P.M. revealed that Resident A1 was placed on 1:1 supervision due to safety issues. There was no facility incident investigation for this event at the time of the survey.
During an interview July 21, 2024 at approximately 2 PM the Director of Nursing that the facility did not report these instances of verbal and mental abuse to the State Survey Agency and local Area Agency on Aging.
Refer F600
28 Pa Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident Rights
| | Plan of Correction - To be completed: 08/21/2024
Resident A1 incidents of verbal and mental abuse will be reported to the State Survey Agency and local Area on Aging.
An initial audit of Risk Management reports will be conducted for the past 14 days to verify verbal and mental abuse were reported to the State Survey Agency and local Area Agency on Aging.
The DON or designee will inservice the Management team on reportable incidents. Risk Management reports will be reviewed during clinical meeting to verify abuse events are reported to the State Survey Agency and local Area Agency on Aging.
The DON or designee will conduct weekly audits x4, then monthly x2 of Risk Management reports to verify instances of abuse have been submitted to the State Survey Agency and local Area Agency on Aging. Results of the audits will be presented at the QAPI meetings for review.
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