|§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.
Based on facility policy review, facility incident report review, clinical record review, and staff interview, it was determined the facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator/Abuse Prevention Coordinator of the facility for two of 22 sampled residents. (Residents 17, 91)
Review of the facility policy entitled, "Patient Protection, Abuse, Neglect, Mistreatment, and Misappropriation Prevention," dated March 30, 2022, revealed the directive that the facility must not use verbal, mental, sexual, or physical abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator of the facility.
Clinical record review revealed that Resident 17 had diagnoses that included anxiety disorder, depression, psychosis (a severe mental disorder), and muscle weakness. The Minimum Data Set (MDS) assessment dated January 25, 2022, indicated that the resident was cognitively impaired; but, was able to state the correct year and recall items after cueing. She required extensive staff assistance for bed mobility, transferring between surfaces, dressing, and personal hygiene. Review of facility witness statements revealed that Resident 17 made an allegation of sexual abuse by a staff member to a nurse aide (NA 1) on February 10, 2022. There was a lack of evidence to support that the facility Administrator (Abuse Prevention Coordinator) was notified within two hours of the allegation or that an investigation had been started until February 11, at 11:00 a.m. Documentation reflected that the Administrator was not notified until February 11, 2022, at 11:30 a.m. During an interview on April 21, 2022, at 1:54 p.m., the Administrator confirmed that Resident 17 made the allegation of sexual abuse during the 3:00 p.m. to 11:00 p.m. nursing shift on February 10, 2022, and that she was not notified until February 11, 2022, at 11:30 a.m.
Clinical record review revealed that Resident 91 had diagnoses that included Parkinson's disease (a chronic and progressive movement disorder) and other symptoms and signs involving cognitive functions and awareness. The MDS assessment dated February 28, 2022, indicated that the resident was cognitively impaired, required supervision for transferring and walking, and required staff assistance for dressing, personal hygiene, and using the toilet. Review of facility witness statements revealed that a nurse aide (NA 2) saw a bruise on the right side of the resident's chest during the night shift on February 8, 2022. When asked by the nurse aide about the bruise the resident stated he did not know what happened. Documentation by the nurse practitioner on February 9, 2022, at 9:30 a.m. indicated that the resident was observed with a contusion and ecchymosis of the right humerus/shoulder, right posterior shoulder, and right anterior upper chest of unknown cause or onset. The facility incident report dated February 9, 2022, at 11:57 a.m., indicated that the injury was identified by the nurse practitioner. There was a lack of evidence to support that the Administrator was immediately notified within two hours regarding the injury of unknown origin. During an interview on April 21, 2022, at 1:54 p.m., the Administrator confirmed that she was not notified of the injury within two hours and was informed following assessment by the nurse practitioner.
28 Pa. Code 211.10(d) Resident care policies.
| ||Plan of Correction - To be completed: 05/26/2022|
1.Residents R17 & R91 were not adversely affected by the deficient practice.
2.Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing the "Patient Protection Practice Guide" all current employees, including agency staff will sign that they received abuse training and reporting education.
3.To ensure the deficient practice does not reoccur, the NHA/designee will educate center staff utilizing "Focus on Ftag 609" on or before the date of compliance.
4.Utilizing the "Abuse Prevention" QAPI tool, the NHA/designee will audit 7 employees weekly for 4 weeks to validate that they understand the reporting requirements for abuse/alleged violations. Any trends will be reported to the QAPI committee for further action planning if needed.