|§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.
Based on a review of the facility's policies, clinical records review, staff, and resident interview, it was determined that the facility failed to thoroughly and timely investigate an injury of unknown origin for two out of 13 Residents reviewed (Resident #8, Resident #21).
A review of the facility nursing policy manual titled "Investigation of Injuries of Unknown Origin", undated, revealed the following: 1. All staff shall be responsible for promptly identifying and reporting all injuries to the nurse on duty. 2. Upon the receipt of the report, the nurse shall immediately evaluate the resident. 3. The bruise/skin tear will be reported through the electronic process which is automatically forwarded to the Director of Nursing (DON), if the injury cause is not immediately known, the nurse shall initiate and complete the first section of the Investigation of Unknown Origin Form. 4. The DON or designee will interview the charge nurses and assigned caregivers of the current and preceding three shifts. The interview should include observations and or resident activities that were witnessed by the staff and that may be related to the cause of injury. 5. All allegation/suspicion of abuse shall be immediately reported to the DON, Nursing Home Administrator (NHA), an abuse investigation will be initiated. 6. If further investigation revealed potential abuse/neglect, the DON will report to the NHA and all authorities as required by the Abuse Prevention policy.
Review of Resident #8's diagnosis list revealed diagnoses not limited to vascular dementia (progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), cerebral infarction (stroke), aphasia (inability to comprehend or formulate language because of damage to specific brain regions), and pseudobulbar affect ( a type of emotional disturbance characterized by uncontrollable episodes of crying and/or laughing, or other emotional displays).
A review of Resident #8's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated December 31, 2019, revealed that Resident #8 had a moderate cognitive impairment. Review of the same MDS revealed that Resident #8 required extensive with two-person assistance with transferring, bed mobility, toileting, and extensive with one-person assistance with personal hygiene and grooming.
Review of the facility progress note dated December 20, 2019, revealed that Resident #8 had behaviors of crying, yelling out, and abusive behaviors.
Review of the facility progress note dated December 26, 2019, at 9:23 p.m., revealed: "Purple bruise under left elbow reported by CNA (nursing assistant), after discussion another CNA reported that she had reported this bruise to the nurse on [name of the unit] last evening". A review of the same progress note revealed that the bruise was four by four centimeters.
Review of the facility documentation, incident report dated December 26, 2019, revealed that on December 26, 2019, at 7:30 p.m., CNA reported a purple bruise under the left elbow after providing care. The bruise had a measurement of four by four centimeters. The incident report further revealed that the Resident was confused.
Additional review of the facility documents, Employee E6 statement, dated December 25, 2019, revealed that while using stand aid (a mechanical lift used for transferring residents) on resident, a bruise approximately three by three on inside elbow, dark purple in color was seen, reported to [name of the nurse].
Review of the facility documentation revealed no documented evidence that Resident #8's bruise of unknown origin identified on December 25, 2019, was investigated, assessed and reported to the DON and NHA. Further review of the facility documentation revealed statements completed by the two-nursing assistant on December 26, 2019, when the bruise on Resident #8 ' s under elbow was observed again during evening care. Both statements do not have any information that can lead to the possible cause of the unknown bruise on resident #8 ' s elbow. The facility failed to provide statements from the caregivers from the preceding shifts.
An interview with the DON on January 9, 2020, at approximately 11:00 a.m., confirmed that no additional statements were completed to determine the cause of Resident #8's bruise on the elbow.
Review of Resident #21's admission MDS assessment dated June 12, 2019, revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment.
Review of Resident #21's incident note of August 18, 2019, revealed "this nurse was doing residents AM care this morning, when this nurse was washing residents lower back this nurse observed bruising to lower back and sacrum area. bruises appear purple in color. lower back bruise measures 5.9x5.3cm and sacrum area bruise measures 5.2x5cm. resident did have a fall on 8/10/19 ".
Review of facility documentation revealed that statements were obtained from the current shift and two of the three preceding shifts. Review of statement obtained from Employee E12 revealed that Employee E12 worked day shift on August 17, 2019, but did not provide direct care to the resident. Review of statement obtained from Employee E13 revealed Employee E13 worked second shift on August 17, 2019, but did not provide direct care to the resident. Review of statement obtained from Employee E14 revealed that Employee E14 worked second shift on August 17, 2019, but did not observe the resident's skin.
Intereview with the DON on January 9, 2020, at 12:27 p.m. indicated that facility procedure is to obtain statements for 24 hours preceding the identification of the injury. The DONconfirmed that statements were not obtained from all preceding three shifts and from staff who provided direct care to Resident #21.
28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 1/31/19
28 Pa. Code 201.18(b)(1)(e)(1)Management
28 Pa. Code 201.29(a)(d) Resident Rights
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code: 211.12(d)(1) Nursing service
Previously cited 1/31/19
| ||Plan of Correction - To be completed: 03/01/2020|
1.The facility will complete thorough and timely investigations for residents with an injury of unknown origin.
a. Resident #8's statements on December 25, 2019 & Residents #21's statements on August 18, 2019 will investigated thoroughly for injury of unknown origin.
2. The Nursing staff are educated on abuse prevention and reporting at new employee orientation and annually. All departments will be re-educated abuse prevention and reporting.
3. The nursing staff will be re-educated on the facility's policy on investigation for injury of unknown origin thoroughly and timely by DON/Designee to ensure.
4. An audit of complete incident reports will be conducted weekly times three months by the DON/Designee to ensure any injury of unknown is thoroughly and timely investigated. Results of Audits will be forwarded to QAPI.
5.This will be completed by 3/1/2020.