§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 the facility's abuse prohibition policy, select investigative reports and clinical records, and interviews with staff and the resident's family it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of six residents sampled (Resident 1) resulting in serious injuries, a fractured thumb and closed head injury.
Findings include:
The facility's policy entitled "Abuse Policy" dated as reviewed by the facility August 30, 2023 revealed that " The facility will not tolerate abuse, neglect, exploitation of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The administrator/abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy."
A review of the clinical record revealed that Resident 1 was admitted to the facility on November 4, 2022, with diagnoses of cerebral infarction (stroke), dysphagia
(difficulty swallowing) requiring enteral feeding through a PEG tube (gastric feeding tube receiving liquid feeding provided through a rubber tube inserted into the stomach) and diabetes, and the need for maximum assistance with personal care.
A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 6, 2024, indicated that the resident required the assistance of two staff member for transfers, bed mobility and toileting and was moderately, cognitively impaired with a BIMS score of 12 (BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment, a score of 8-12 indicated moderate cognitively impaired).
A review of the resident's current plan of care, initially dated March 27, 2023, revealed a care plan in place for ADL (activities of daily living) self-care performance deficit related to cerebral infarction and weakness. Resident 1 could answer questions with one /two words.
Planned interventions, upon admission, indicated that the resident required the use of a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with the assistance of two staff for transfers, was dependent on two staff for bed mobility and toileting, and was non-ambulatory.
A facility investigation report dated May 21, 2024, revealed that Resident 1, had a BIMS score at the time of the incident 14 out of 15, indicating cognitively intact, and reported that he rolled out of bed while a nurse aide was providing his care. The resident stated that Employee 1, a nurse aide, was providing his care and he fell out of bed. Employee 1 then left the room to get another staff member and they both assisted him back into bed.
A review of a witness statement dated May 22, 2024 (no time indicated) Resident 1 answered the following questions asked by the Nursing Home Administrator (NHA) and the RN corporate consultant:
-Do you remember when you fell? "Yes"
-Do you know who picked you up off the floor? "Yes"
-You previously stated, it was Employee 1, nurse aide. Is that correct? "Yes"
-Did she have help? "Yes"
-Do you know who helped her? "Yes"
-Did you ever see the person before the night that she assisted you off the floor? "Yes"
The facility reviewed their surveillance camera footage, revealed to ascertain who entered and left Resident 1's room. A new employee (Employee 5, a nurse aide orientee) started on the 11 PM to 7AM shift and a nurse aide on the 3 PM shift worked that hallway and had not worked in that hall before. Following the facility's review of the footage, they asked Resident 1 the following questions:
-Can you tell me if the employee was black or white? "Black"
-Did she have light or dark hair? "Dark"
Resident 1 was unable to convey whether his fall occurred on the 3 PM to 11 PM shift.
- Did the nurse come to assess you after you fell? "No"
- Did Employee 1 provide care for you by herself? "Yes"
-Do you have any pain? "No"
-Do you feel safe? "Yes"
A review of a witness statement dated May 21, 2024, (no time indicated) from Employee 1, a nurse aide, revealed that "While providing care to I saw a red swelling on his forehead. I continued to wash him up and when I was done, I told Employee 3 (RN Supr), when I did not see the nurse (the LPN assigned to the unit). I did not observe \ on the floor at any time. I did not assist \ off the floor. I reported to Employee 3 (RN Supr) and the Director of Nursing (DON) when she came in the morning.
The NHA and corporate nurse consultant asked Employee 1 on May 22, 2024:
-What time did you provide care? "Later in the evening"
-What time did you see the swelling? "Later in the evening when washing him up"
-Who did you provide care with you, to this resident? "Employee 2" a nurse aide
-How many times did you provide care to Resident 1 on the 11 PM to 7 AM shift and who was with you each time? "I don't remember"
A review of a witness statement dated May 21, 2024, at 11:19 A.M., Employee 2 stated, "I assisted Employee 1 to provide care for Resident 1. While providing care, Employee 1 noticed a red mark and swelling on his forehead. We finished care and Employee 1 reported this to Employee 3 (RN Supr), the supervisor.
Additional questions asked of Employee 2:
-What time did you provide care? "Sometime after dinner"
-What time did you and Employee 1 report the red area? "Employee 1 reported, but not sure what time"
A review of a witness statement dated May 21, 2024, at 12:20 PM Employee 5, nurse aide orientee, indicated that "Monday May 20, 2024, 11 PM to 7 AM shift was my first physical shift of nurse aide training. I was assigned with Employee 1. I did not witness any resident falls, injuries or incidents during that time."
Additional questions asked of Employee 5 during the interview:
-Did you provide care to Resident 1 with Employee 1? "I shadowed Employee 1 on the 11 PM to 7 AM shift and I do not know the residents yet by name or initials. I accompanied Employee 1 in each room that shift."
A review of a witness statement dated May 21, 2024, from Employee 3 (RN Supr) revealed that Employee 3 stated that "Employee 1 came to me and told me he (Resident 1) has a little red area on his head. I checked his chart (clinical record) and there was nothing charted of anything that might have happened. I then came to his room to assess and at that moment there was slight reddened to his head. No hematoma present. He did not complain of any pain.
The facility's administrative staff asked Employee 3 the following additional questions:
-Did you ask the resident how he got the red area? No, I asked him if it hurt. He stated "no" and smiled.
-Did you interview the nurse aides if anything happened to him? "No"
A witness statement no date or time indicated from Employee 6 LPN, revealed that the employee stated "I was on duty Monday May 20, 2024, on the 3 PM to 11 PM shift. I went to give meds to \ twice, around 5:30 PM to 6 PM and 8 PM. The resident was fine, without any bruises or marks at any parts of his body. If anything happened during my shift, it was not reported to me."
A witness statement dated May 21, 2024, from Employee 4, nurse aide, stated "Around 10:30 AM (May 21, 2024) My co worker and I went to provide ADLs to We noticed swelling and bruising to left eye and forehead injury and left leg and right finger injury. The RN supervisor and DON notified immediately."
A witness statement dated May 21, 2024, (no time indicated) from Employee 7, a nurse aide, stated "my coworker and I were about to do ADLs and noticed swelling and bruising to his \ left eye and forehead, injury to left leg and right finger. This was immediately reported to the Supervisor and DON."
A witness statement dated May 29, 2024 (no time indicated) Employee 8, LPN, stated that "on May 21, 2024, she was called to \ room by nurse aide staff at approximately 10:30 AM Upon entering the room, this nurse observed multiple discolorations and lacerations, swelling on the left side of his head and face. The NHA was notified." Employee 8 stated that she had been in the resident's room perviously on that shift at 9 AM to administer his medications through the g-tube. He was covered up and his head was turned at that time when the meds were given, stating "I did not observe anything at that time. He was sleeping at that time."
A review of the resident's clinical record revealed that there was no nursing documentation entered on May 20, 2024, during the 3 PM to 11 PM or May 21, 2024, on the 11 PM to 7 AM shifts.
A review of facility staffing documents revealed that Employee 1 worked May 20, 2024, on the 3 PM to 11 PM shift and May 20th into May 21, 2024, 11 PM to 7 AM shift. Employee 3 (RN Supr) worked May 20, 2024, 7 PM to 11 PM and May 20th into May 21, 2024, 11 PM to 7 AM shifts.
There was documented evidence that the licensed and professional nursing staff had conducted a thorough nursing assessment, including neuro checks, on May 20, 2024, during the 3 PM to 11 PM and 11 PM to 7 AM shifts in response to the resident's reported fall and observed facial and head injuries.
A review of a nursing wound summary report dated May 21, 2024, at 10:45 PM revealed the resident sustained the following injuries:
- a bruise to the right thumb, measuring 1.5 cm x 2 cm
-a bruise to the left forehead measuring 4 cm x 3 cm
-a bruise to the left eye, measuring 4 cm x 1,5 cm
-a laceration to the left cheek, measuring 2 cm x 0.1 cm
-a skin tear to the left shoulder measuring 0.9 cm x 0.7 cm
-a skin tear to the right, top of the foot, right medial skin tear measuring 2 cm x 0.5 cm
-skin tear to the left knee measuring 3.8 cm x 0.9 cm
-a skin tear to the left lateral knee measuring 2.5 cm x 0.8 cm
There was no additional description of these wounds in the resident's clinical record at the time of the survey ending June 4, 2024, to include the characteristics/appearance of the skin condition or any bleeding.
A review of nursing documentation dated May 21, 2024 at 10:50 AM "Resident was interviewed, feels safe while in facility and pleasant, no pain noted, will continue to monitor. MD aware. Wife was called and still awaiting a call. Multiple areas noted as well as a hematoma to his left forehead. RN provided a full body assessment. Tylenol was immediately offered, resident did not accept and stated he was fine but accepted Tylenol a few hours later. The physician was notified and gave new orders for ice pack and x-rays of resident's right hand and left shoulder. Resident stated that he rolled out of bed as he was being cared for during the night time hours. Resident stated a NA was providing care while he rolled out of bed onto floor. She left the room to get another staff member and they assisted him back into bed. Resident was unsure of the other person who assisted the CNA. An immediate investigation with statements was initiated from all staff that had come in contact with resident. Resident then notified us of the name of the NA that he stated was changing resident."
A review of a social services note dated May 21, 2024, at 2:33 PM revealed "SS paid resident a supportive visit following a fall incident. Resident expressed that he was upset about the fall and in discomfort. The nurse came in and gave resident pain relief and he denied any further concerns or pain."
A nurse's note dated May 21, 2024, at 1:57 PM revealed "Resident to be sent out to the Hospital to evaluate for status post fall." A nursing entry May 21, 2024 at 4:21 PM revealed, "resident being sent out to evaluate for self-reporting a fall on May 20, 2024. Resident has multiple skin tears, a bump and bruise on his left head, a black left eye, and a bruise on his right thumb with edema and pain. X-ray of left shoulder negative for fracture. X-ray of right hand cannot rule out fracture. Resident complained of intermittent headache, right hand pain, left shoulder pain, does not like ice pack due to cold. Spouse requesting resident be sent out for evaluation. Physician notified. EMS arrived to bring resident to Emergency department. Sent to the hospital."
A review of hospital documentation dated May 21, 2024, revealed that the resident's diagnoses included a displaced fracture of distal phalanx of right thumb, a closed head injury, contusion of left orbital tissues, neck and left shoulder pain. The resident received a CT scan (Uses several X-ray images and computer processing to create cross sectional images) of the head, cervical spine, chest, hand and shoulder X-Rays. Tylenol was administered and a dressing and splint applied. Right thumb swollen and bruised, patient tender to palpation, particular with palpation of the distal portion. Small abrasions not amenable to repair noted to the right foot as well as the left knee, significant tenderness to palpation of those areas. Presentation as above with fracture of the distal phalanx of the right thumb as well as shoulder pain and neck pain and contusion of the left orbit and closed head injury status post fall. Vital signs and examination as above.
A nurses note dated May 21, 2024 at 10:40 P.M. revealed "Resident returned from the hospital and wife present. Resident diagnosis with displaced fracture of distal phalanx of right thumb. Resident arrived with splint to right thumb. Resident is to follow up with Ortho."
During an interview on June 4, 2024, at 12 PM, Resident 1's wife stated that she visits her husband daily. She stated that he told her that the nurse aide rolled him out of bed. He fell to the floor and rolled underneath the bed. The nurse aide left him on the floor and returned with another nurse aide. The two nurse aides then picked him up from the floor, without using the mechanical lift (as is his transfer status, mechanical lift and assist of 2 staff). She stated that she felt that the multiple cuts and skin tears he sustained were due the two nurse aides pulling him out from under the bed.
Employee 1 was caring for the resident, while he was in bed, without the assistance of another nurse aide, and the resident rolled out of bed. Employee 1 failed to report the resident's fall and sought the assistance of another nurse aide to put the resident back to bed, without the use of a mechanical lift. These nurse aides did not report the resident's fall. Upon report of the resident's head and facial injuries, licensed and professional nursing staff failed to promptly assess the resident and initiate checks of the resident's neurological status
An interview with the Nursing Home Administrator and Director of Nursing on June 4, 2024, at approximately 2 PM confirmed that the facility's nursing staff failed to provide resident Resident 1 with the care and services necessary to avoid physical harm. The NHA and DON confirmed that Employee 1 was aware that the resident's bed mobility and transfer were to performed with two people but neglected to assure the presence of a second person for the resident's care, and did not use the mechanical lift to assist the resident back to bed after the fall, and failed to report the incident to assure the resident received timely and necessary care.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a)(c) Resident Rights
28 Pa. Code 211.12 (c)(d)(5) Nursing Services
| | Plan of Correction - To be completed: 06/26/2024
Step 1
Rn assessment completed. X-rays completed. Pain assessment completed. MD and RP aware.
AAA made aware, Stroudsburg police made aware, DOH report filed.
Step 2
To identify like residents that have the potential to be affected the SW/designee will complete interviews of residents with a BIMS of 12-15 to review if they have ever fallen and not been assessed by a nurse, If they have the proper assistance with the level of care that they need such as bed mobility and transfers, do they feel safe in the community.
To identify like residents that have the potential to be affected the DON/designee will complete skin sweeps on all incapable residents with a BIMs of 11-99 to ensure there are no s/s of abuse or injuries of unknown origin.
To identify like residents that have the potential to be affected the DON/designee will review new current admissions going back to 4/8/24 to ensure new residents admitted have their kardex updated in matrix.
To identify like residents that have the potential to be affected the DON/Designee will review current residents progress notes and CNA documentation going back 7 days to ensure all areas of skin impairment have an appropriate assessment and if applicable event report and wound measurement.
Step 3
To prevent this from happening again the DON/designee will educate current employees on the abuse policy with focus on neglect and ensuring abuse is reported immediately. Abuse quiz will accompany.
To prevent this from happening again the DON/designee will educate CNAS on ensuring they know where the kardex's are on paper and how to access the kardex in matrix. This will ensure all CNAS know how to care for the resident. Quiz will accompany.
To prevent this from happening again the DON/designee will educate licensed staff on ensuring if it is reported that resident has an area of skin impairment or fall that the RN will complete an assessment and event report and document this in the EHR. Wound assessments will be completed by the RN.
To prevent this from happening again the DON/designee will educate nursing staff that unless a resident can independently get off the floor during a fall the mechanical lift will be used unless contraindicated.
Step 4
To monitor and maintain ingoing compliance the NHA/designee will interview five random employees weekly x 4 then monthly x 2 on the abuse policy to ensure understanding.
To monitor and maintain ongoing compliance the SW/designee will interview five capable residents with a BIMS of 12-15 weekly x 4 then monthly x 2 to review if they have ever fallen and not been assessed by a nurse, If they have the proper assistance with the level of care that they need such as bed mobility and transfers, do they feel safe in the community.
To monitor and maintain ongoing compliance the DON/Designee will complete skin sweeps on five incapable residents with a BIMS of 11-99 to ensure there are no s/s of abuse or injuries of unknown origin.
To monitor and maintain ongoing compliance the ADON/designee will observe 5 random employees weekly x 4 then monthly x2 to ensure they know where the paper kardex's are and they know how to access the kardex on matrix to ensure they know how to provide care to the resident.
To monitor and maintain ongoing compliance the DON/designee will complete observation audits of five residents weekly x 4 then monthly x 2 to ensure residents are being provided care such as bed mobility and transfers with the proper assistance level.
To monitor and maintain ongoing compliance the DON/designee will review documentation weekly x 4 then monthly x 2 to ensure if an area is identified there is an RN assessment, documentation in matrix, and if applicable event report.
To monitor and maintain ongoing compliance the DON/designee will review residents that have a fall weekly x 4 then monthly x 2 to ensure the mechanical lift was used for transfer from the floor if applicable.
To monitor and maintain ongoing compliance the DON /designee will progress notes and CNA documentation weekly x 4 then monthly x2 to ensure all areas of skin impairment have an appropriate assessment and if applicable event report and wound measurement.
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