§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;
|
Observations:
Based on facility policy review, clinical record review, facility documentation review, and staff interview, it was determined the facility failed to ensure each resident was free from neglect, which resulted in actual harm as evidenced by fracture of the right hip for one of three residents reviewed (Resident 1).
Findings Include:
Review of facility policy, titled "OPS 300 Abuse Prohibition" with a last revision date of October 24, 2022, revealed "Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress."
Review of Resident 1's clinical record revealed diagnoses that included history of cerebral infarction (also known as "stroke" or cerebral vascular accident sudden loss of blood flow or bleeding into the brain that causes brain cell death), right- above the knee amputation and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment).
Review of Resident 1's comprehensive plan of care revealed a care plan with a focus of, "ADL [Activities of Daily Living] self care deficit as evidenced by generalized weakness related to physical limitations, history of [cerebral vascular accident]," which was last revised August 23, 2024.
Review of Resident 1's ADL care plan revealed the intervention of, "ADL Assist: Assist of two [staff members] with ADL's," which was last revised on April 17, 2024.
Review of Resident 1's Kardex (quick reference tool utilized to identify a resident's care needs/preferences and assistance needed) revealed section titled, "Dressing/Grooming/Bathing," which stated, "ADL Assist of two with ADL's."
Review of facility incident report dated October 16, 2025, revealed Resident 1 sustained a witnessed fall from bed at 11:45 AM. Review of the "Incident Description," revealed it stated, "During brief change [Resident 1] was holding on the [sic] arm of the chair next to bed and the chair moved and [Resident 1] kept rolling off the bed and was lowered to the floor by CNA [Employee 1 Nurse Aide]."
Review of Resident 1's interdisciplinary progress notes revealed that an assessment conducted by the Registered Nurse revealed Resident 1 had pain in the right hip, left knee and ankle, and that an x-ray of the area had been ordered.
Review of X-ray results dated October 16, 2025, revealed Resident 1 suffered a right-sided acute intertrochanteric fracture (hip fracture). Resident 1 was subsequently sent to the hospital emergency room for evaluation and treatment. Resident 1 was considered for surgery; however, found not to be a candidate for surgery due to health conditions.
Review of a witness statement by Employee 1 dated October 16, 2025, revealed Employee 1 stated, "I did not know that [Resident 1] needed 2 people until after the incident. I did check her Kardex and did not see where it said 2 assist for toileting. I was providing incontinence care, I was not aware that incontinence care is considered an ADL ..."
Review of the Care Plan and Kardex for Resident 1 revealed that the only assist level noted during the time of the fall was for a two person assist.
Review of Employee 1's facility education revealed that Employee 1 completed the following education modules:
"Bed safety" on October 9, 2025.
"Abuse &; Neglect OTS" on September 5, 2025.
"2025 Q3 Mandatory Safe Resident Handling Training Clinical Employees," on July 3, 2025.
"Safe Resident Handling: Active Transfers and Mobility Clinical Staff," on July 3, 2025.
"SQ LTC: Falls, Assessment and Prevention," on July 3, 2025.
"Patient Rights and abuse &; Neglect Prevention," on June 20, 2025.
"SQ LTC: Abuse and Neglect," on April 6, 2025.
"SQ LTC: Patient or Resident Safety Basics, Patient-Facing," on April 6, 2025.
Employee 1 failed to follow the plan of care for Resident 1 and proved incontinence care independently, instead of with a second employee, which resulted in Resident 1 falling from her bed and sustaining a right hip fracture.
During staff interview with the Nursing Home Administrator (NHA) on October 23, 2025, at approximately 11:45 AM, he confirmed that Employee 1 neglected to follow the plan of care for Resident 1 by failing to provide ADL care with two staff, which resulted in Resident 1 falling from the bed.
During the staff interview, the NHA confirmed that Employee 1 was terminated from her position as a result of the facility investigation.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18 (b)(1)(e)(1) Management
28 Pa. Code 201.29 (a) Resident rights
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 12/17/2025
Unable to retroactively correct Resident 1's fall since the ADL plan of care was accurate and in place.
A Comprehensive review of current residents will be conducted to ensure that ADL transfer statuses are in place and reflected on the Kardex and care plan.
The facility will take further steps to ensure that the problem does not recur by in-servicing all nursing staff on F tag 600 with a focus on ADL safe resident handling and where to locate the kardex, as well as "Turning and Positioning Guidelines" Policy.
Compliance will be monitored by the Director of Nursing/Designee using the Safe Resident Handling Audit and Safe Resident Handling Staff Training Audit to review all new residents weekly x 3 weeks then monthly x 2 months to ensure that ADL's are in place on the kardex as ordered and that Training Programs are being completed and documented. Five random direct observation audits will be completed weekly x 3 weeks then monthly x 2 months to ensure that ADL care is being provided per plan of care with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.
|
|
