§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 review of facility policy, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of three sampled residents (Resident R1).
Findings include:
Review of facility policy "Abuse, Neglect, and Exploitation" dated 8/3/23, indicated it is the facility policy to investigate all suspicions and incidents of neglect and injuries of unknown source. It was indicated written statements must be obtained from the resident, if possible, the accused, and each witness. It was indicated if there are no direct witnesses, then the interviews may be expanded.
The facility policy "Fall Prevention and Management Policy" last reviewed 7/1/23, indicated all falls will be reviewed and investigated.
Review of the clinical record indicated that Resident R1's was admitted to the facility on 12/19/23. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses fall, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), generalized weakness.
Review of Resident R1's care plan dated 1/29/24, indicated the resident was at risk of falling.
Review of Resident R1's "Event Report" dated 2/5/24, entered by Registered Nurse, Employee E2 indicated Resident R1 had a fall with minor injury. It was indicated the resident had a "bump" on her head.
Review of the facility's "Post Fall Huddle (PFH) Form" that was not dated or signed, indicated Resident R1 had a fall on 2/5/24, at 12:45 a.m. It was indicated Registered Nurse (RN), Employee E1, RN, Employee E2, and Nurse Aide (NA), Employee E3 assisted the resident after the fall.
Review of Resident R1's investigation report failed to include NA, Employee E3's witness statement and a statement from the resident.
During an interview on 2/21/24, at 12:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse as required for one of three residents (Resident R1).
28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee. 28 Pa. Code: 201.18 (e)(1) Management.
| | Plan of Correction - To be completed: 03/21/2024
I. DON/Designee will conduct a full investigation on R1's identified fall incidents to rule out neglect and/or abuse. R 1's fall incident has been investigated and E 3's statement has been obtained. II.To identify other residents with the potential to be affected, NHA and DON will conduct a 30 day review of fall incidents to ensure a thorough investigation was completed to rule out abuse or neglect. Facility will conduct a 30 day look back on all fall incidents to ensure post assessments and orders are followed, documentation, resolution, and response was completed. Moving forward, facility will thoroughly investigate, resolve and document all fall incidents. III. To prevent this from reoccurring, DON/designee will educate Licensed staff on how to conduct an investigation at time of occurrence, to include staff statements. NHA/Designee will re-educate staff on investigating all fall incidents. IV. Ongoing monitoring for compliance, NHA/Designee will audit ensure a thorough investigation was completed and to rule out any abuse or neglect incidents weekly x4 and monthly for 2 months.
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