§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.
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Observations:
Based on a review of facility policies, facility documentation, review of clinical records and interviews with residents and staff, it was determined that the facility failed to conduct a thorough investigation related to an allegation of verbal and physical abuse for one of two residents (Resident R1).
Findings include:
Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on September 23, 2023, with diagnoses of Unspecified Intellectual Disability, Post Traumatic Stress Disorder (PTSD), Transsexualism, and Anxiety Disorder.
Review of Resident R1's Quarterly MDS (minimum data set, a federally required resident assessment completed at a specific interval) assessment dated November 4, 2024 Section C0500 BIMS (brief interview of mental status) score revealed that Resident R1 scored 15, suggesting that Resident R1 was cognitively intact.
Review of resident's care plan revealed that a care plan was developed on November 6, 2024 for the resident having the potential to be physically aggressive towards staff and/or other residents in relation to anger, and poor impulse control.
Continued review of the resident's care plan revealed that on February 21, 2024 a care plan was developed related to Resident R1's behaviors which included to unable to effective cope with anxiety, depression, intellectual disability, transsexualism, PTSD, physical assault, nightmares of committing suicide with no suicidal plan while awake and nightmares of being killed in shelter: paranoid/delusional accusatory/argumentative towards others regarding sexual orientation and loudly expressing inappropriate statements, and accusatory of staff i.e. (throwing water at him).
Further review of the resident's care plan revealed that the resident has a behavior problem with seeking attention from male employees. Resident has history of these behaviors. Date initiated: September 20, 2024.
Interview with Resident R1 conduced on November 26, 2024, at 9:39 a.m. revealed that a female employee doesn't like him because he is gay. Further Resident R1 also revealed that the female employee called him a faggot and that he reported it to the facility staff, but nobody did anything about it. Further interview with Resident R1 revealed that he did not remember the name of the employee.
Interview with Social Worker, Employee E4 conducted on November 26, 2024, at 11:48 a.m. revealed that back in September, 2024 Resident R1 reported to him that a staff called him a faggot.
Further interview with Social Worker, Employee E4 revealed that he filled out a Resident Concern Form (a form, the facility uses to document resident complaints and concerns which will then be investigated, and the investigation and its conclusion is documented on the same form) and submitted the Resident Complaint Form to the Director of Social Services.
Interview with Nursing Home Administrator, Employee E1 revealed that he was not aware of Resident R1's allegation that a staff member called him a faggot. Further, Employee E1 was not aware of an investigation conducted to address Resident R1's above allegation.
Review of Resident Concern Form dated September 10, 2024, completed by Social Worker, Employee E4 revealed that the concern was voiced by individual/family, Resident involved was Resident R1.
Review of the Resident Concern Form section "Detail of concern" revealed that Resident R1 stated that he had a verbal confrontation with Nurse aide, Employee E6. And that during the confrontation, Employee E6 called him a faggot.
Further review of the resident's concern form revealed that the following sections were not completed (left blank): Employee investigating the concern, findings, and disposition, whether the concern was confirmed or not, whether the resident/responsible party was notified, date that the resident/responsible party was notified, name of the person notified, and follow-up section (if applicable). Further the section for the administrator's signature and date at the bottom of the form was not signed.
Review of a written statement dated September 10, 2024, completed by Assistant Director of Nursing (ADON), Employee E3 revealed that Resident R1 also revealed that a nurse's aide called him a faggot.
Review of facility documents revealed that there was no evidence that the above resident's concern was investigated.
Review of facility documents revealed no documented evidence that an investigation was conducted related to resident's report of staff calling him a faggot. There was no conclusion as to whether the allegation was substantiated or not.
Interview with the Director of Social Services, Employee E5 conducted on November 26, 2024, at 1:05 pm confirmed that Employee E4 submitted a report alleging that a staff member called him a faggot. Further, the Director of Social Services, Employee E5, confirmed that an investigation was not conducted to address Resident R1's above allegation.
Interview with ADON, Employee E3 conducted on November 26, 2024, at 1:18 pm revealed that the facility collected statements from staff.
Further interview with ADON, Employee E3 confirmed that Resident R1's above allegation was not investigated and was not reported to the department of health. Further, Employee E3 revealed that the staff involved in the allegation was terminated due to reasons unrelated to the incident
Review of psychology note dated November 6, 2024, revealed that Resident R1 reported that staff hit him on the nose with a door.
Interview with Director of Nursing (DON), Employee E2 and ADON, Employee E3 conducted on November 26, 2024, at 11:06 am revealed that they were not aware that Resident R1 reported to the psychologist that a staff hit him on the nose with a door. Further DON, Employee E2 and ADON, Employee E3 revealed that the Psychologist did not report the incident to anyone.
Further interview with ADON, Employee E3 and Social Worker, Employee E4 confirmed that Resident R1's allegation that a staff hit him on the nose with a door was not investigated and was not reported to the State Department of Health.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 12/12/2024
An investigation of both the allegation of verbal and physical abuse for Resident R1 has been completed. Both allegations are unsubstantiated.
All residents have the potential to be affected by the alleged deficient practice. A two week look back of all allegations of abuse will be conducted to ensure an investigation was completed. An audit form was created to ensure investigations are completed on all allegations of abuse.
The DON/ designee will educate the psychiatrist and staff on abuse policy and reporting allegations. All investigations will be discussed during morning meeting.
Investigations will be audited weekly x4 and then monthly x 2 for accurate completion. Findings will be reported during monthly QAPI meetings.
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