§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.
|
Observations:
Based on review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure all allegations of suspected abuse were reported, as required, to the Department of Health for one of four allegations reviewed (Resident R2).
Findings include:
of Resident R2's clinical record revealed on February 14, 2026, Resident R2 reported that while coming back from smoke break, a third-floor resident pulled his/her hair, and Resident R2 was calling the police to press charges. Resident R2 was assessed, with no redness, swelling, bleeding or visible injury noted to residentscalp.
with Medical Records, Employee E3, on September 3, 2026, at 9:45 a.m. reported that there was no resident with the last name that Resident R2 had given but Employee E3 will investigate the matter. Employee E3 was able to provide the surveyor with the progress notes and incident report which identified the alleged perpetrator (Resident R7).
of the facilitydocumentation revealed that on February 14, 2026, the facility did investigate the resident-to-resident physical altercation.
with Director of Nursing, Employee E2, on September 3, 2026, at 12:45 p.m. reported that an investigation was conducted but was unaware that resident-to-resident suspected abuse had to be reported to the State Survey Agency.
review of information submitted by the facility to the State Survey Agencyno reported events by the facility for Resident R2.
Pa. Code 201.14 (a) Responsibility of licensee.
28 Pa. Code 201.18 (b)(1) Management.
| | Plan of Correction - To be completed: 10/15/2026
An event report was submitted regarding suspected abuse related to an incident between R2 and R7.
A 6 month look back was conducted of all resident to resident altercations to ensure potential suspected abuse has been reported accordingly.
DON was re-educated on reporting requirements related to suspected abuse and resident to resident altercations.
DON or designee will audit risk management system weekly x 4 weeks then monthly x 3 months to ensure resident to resident altercations are reviewed and reported accordingly for suspected abuse.
Results will be reviewed during the facility's monthly QAPI meeting. QA meeting will determine the need for continued auditing.
|
|
