§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 review of facility policies, facility documentation, clinical records and staff interviews, it was determined that the facility failed to protect residents from neglect for one of eighteen residents reviewed (Resident 47). Resulting in actual harm of skin tear and bruising to Resident 47.
Findings include:
The facility's policy "Preventing Resident abuse" revised April 2019, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Additional review of same policy defines neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness.
Review of Resident 47's clinical record indicated Resident 47 was admitted to the facility on July 11, 2019.
Review of Resident 47's Minimum Data Set (MDS - periodic assessment of care needs) dated January 31, 2024, indicated Resident 26's diagnoses include but not limited to Alzheimer's disease (decline in memory, thinking, learning and organizing skills over time.), Peripheral Artery Disease (condition of narrowed arteries reducing blood flow to the arms or legs), Depression (persistent feeling of sadness and loss of interest), and Anxiety
Further review of Resident 47's MDS dated January 31, 2023 Section C; revealed a completed Brief Interview for Mental Status (BIMS -tool used to measure a person's cognition) with score of 3 (indicating severe impairment).
Review of Resident 47's ADL (Activities of Daily Living) care plan dated December 27, 2023, revealed the following interventions for Resident 47: requires an assist for two for bed mobility (initiated on July 11, 2019), requires an assist of two for transfers (initiated on July 11, 2019), requires an assist of one for dressing (initiated July 11, 2019), and requires an assist of one with personal hygiene (initiated on July 11, 2019).
Review of Resident 47's clinical record revealed Resident 47 was administered the following medications: Eliquis (blood thinner used to prevent blood clots), Remeron (used to treat depression), Ativan (used to treat anxiety).
Review of information dated September 4, 2023 submitted by the facility submitted on September 4, 2023 revealed Resident 47 experienced neglect during afternoon care on September 4, 2023, at 11:30 a.m. from Certified Nursing Assistant (CNA) Employee E1.
Further review of the information dated September 4, 2023 submitted on September 4, 2023 summarized; "E1 entered Resident 47's room to get resident up and dressed, per E1 [he/she] told Resident 47 it was time to get ready for lunch, informing [resident] [he/she] was going to wash and dress [resident]. Resident 47 responded "get the hell out of here". E1 went and gathered [his/her] supplies and reapproached the Resident 47, Resident 47 did not respond, so E1 initiated care, Resident 47 was calm until E1 began providing incontinence care when Resident 47 began to yell and tried to swing back and hit E1. E1 placed Resident 47 on [resident] back and calmly asked what is wrong, Resident 47 continued to yell "Get the hell away from me." E1 waited a minute until Resident 47 calmed and explained once again, we have to get dressed. E1 then continued to wash Resident 47's bottom, Resident 47 pushed back and began to hit, at that time the E1 folded Resident 47's arms on her chest and tried to get a brief on her. E1 let [resident] arms go to roll Resident 47 back to the right side, as E1 did the Resident 47 started swinging [his/her] arms and trying to bite E1. When E1 sat Resident 47 on the side of the bed, E1 saw a skin tear. Resident 47 was calmed and assisted with transferring [resident] to the recliner with walker to chair, Resident 47 then began to yell "get the hell out of here" and E1 immediately reported skin tear."
Review of Nurse Aide, Employee E2 witness statement dated September 4, 2023, indicated there was bruising on Resident 47's left arm and bruising and a skin tear on Resident 47's right arm. E2 also indicated, "I went to check on Resident 47 at 2:15 p.m. and Resident 47 said "she held both of my arms and there was nothing I could do."
Review of Nurse Aide, Employee E1's witness statement revealed, Nurse Aide, Employee E1 folded Resident 47's arms against her chest which resulted in Resident 47 sustaining multiple bruises and skin tears.
Review of facility investigative documentation including the PB-22 (form that is utilized to report instances of abuse, neglect, or exploitation of vulnerable adults) completed by the facility dated September 6, 2023, at 3:18 p.m. substantiated the information indicated above and concluded that Resident 47 experienced neglect from E1 resulting in "bruising and skin tears to bilateral (right and left) lower arms."
Additional review facility investigative document PB-22 revealed E1 "was removed from the facility and placed on the do not return list, [Nursing Agency] employer notified via phone call of events and staff member status."
Review of Resident 47's clinical record revealed a progress note by psychiatric-mental health nurse practitioner (PMHNP) dated September 5, 2023, at 7:00 p.m. indicating, "contacted by SW (social worker). Resident 47 with recent increase in aggression. Hit and bit staff. Aggressive with care. DVT (Deep vein thrombosis, a blood clot forms in one or more of the deep veins in the body) currently being treated. Increased pain. Probable increase in anxiety r/t (related to) care. Recommend Ativan .25 mg (milligrams) q (every) 12 hours for anxiety x 14 days. Hold of sedation."
Resident 47 was unavailable for an interview due to being admitted to the hospital on March 3, 2024.
Interview conducted with the Nursing Home Administrator (NHA) on March 8, 2024, at 10:30 a.m. confirmed that the facility failed to protect residents from abuse for one of eighteen residents reviewed resulting in actual harm to the resident (Resident 47).
28 Pa Code: 201.14 (a ) Responsibility of licensee
28 Pa Code: 201.18 (b)(1)(3) Management
28 Pa Code: 211.10 (d) Resident care policies
28 Pa Code 211.12 (d)(3) Nursing services
| | Plan of Correction - To be completed: 04/03/2024
This POC does not constitute an admission of or agreement with the alleged facts and conclusions set forth on the survey report. It is prepared and executed solely as a means to continually improve quality of care and to comply with all applicable state and federal regulatory requirements.
1. Resident 47 care plan has been reviewed and reflects the changes made at the time of the event. Incident Report review reveals no other residents identified to have been affected by the event.
2. DON/Designee shall provide nursing staff education on Abuse, Neglect and Exploitation.
3. Administrator and DON shall review and update the Facility Agency Orientation packet to ensure effective education of Abuse, Neglect and Exploitation is present prior to agency personnel working in the facility.
4. DON/designee shall provide education for nursing staff on providing care for residents with cognitive impairment and challenging behaviors.
5. All Incident Reports shall be monitored weekly for eight weeks by the DON and Administrator to ensure proper investigative procedures are being followed weekly. Results shall be communicated in QAPI committee for review and recommendation.
6. All Grievance/Concern Forms shall be monitored by the Social Worker and Administrator weekly for eight weeks to ensure proper investigation and follow up is being completed. Results shall be communicated in QAPI committee for review and recommendation.
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