§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 review of policies, clinical records, and grievance/complaint investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of four residents reviewed (Resident 1).
Findings include:
The facility's policy regarding abuse, dated August 29, 2023, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property. The facility would investigate all alleged, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property, and injuries of unknown source. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 20, 2023, revealed that the resident could understand and was understood. A care plan for an Activities of Daily Living (ADL) self-care deficit, dated February 12, 2024, indicated that staff was to encourage the resident to use the call bell to call for assistance as needed. That the resident was at risk for falls and staff was to always keep the call light in reach and to keep personal items and frequently used items within reach.
An interview with Resident 1, completed by Registered Nurse 1, dated January 24, 2024, revealed that on January 24, 2024, at shift change, Agency Nurse Aide 2 (on the 400-unit) asked the registered nurse to go speak with Resident 1 regarding an incident that happened in the evening, and she did not want to be inadvertently associated with it. Agency Nurse Aide 3 from an unknown agency was working the first assignment on the 400 unit. Per Resident 1's report, Agency Nurse Aide 3 was rough with him during evening care, which he did not think too much of. Afterwards, Nurse Aide 3 did not place the bed remote and call light within his reach, to which Resident 1 asked her for these items. Resident 1 claims that Nurse Aide 3 stated she would give him back the call bell only if he agrees to not ring out until 10:00 p.m. Resident 1 stated he does not utilize the call bell except for emergencies and continued to ask for the call light back. At this time, Resident 1 stated that Nurse Aide 3 began to offer and retract the call light to him in a game-like manner that was upsetting to him. Resident 1 stated he then told Nurse Aide 3 to "give him his damn call light," to which Nurse Aide 3 then refused because the resident was swearing. Nurse Aide 3 then dropped the call light in the resident's trash can and left the room, closing the door behind her. Resident 1 stated that the heat was turned on in the room, making it very hot, and that he was unable to utilize the call bell, and that his door was closed. Resident 1 stated that he does not want to be at this facility and spends too much money to be here and to be treated in this manner. Resident 1 asked the writer to have Nurse Aide 3 terminated. The writer explained that Nurse Aide 3 was an outside agency staff, but that this matter would be addressed in a formal grievance to be handled by the appropriate management. Resident 1 seemed pleased with this outcome.
Interview with the Resident 1 on March 13, 2024, at 2:45 p.m. revealed that he had asked Nurse Aide 3 to do something for him but he could not recall what it was. He indicated that she became rude, so he became rude right back. That is when she took his call light off him and placed it in the garbage can where he could not reach it. He indicated that she then left the room and shut the door. He indicated that it was concerning to him because he was not able to reach the call bell if needed, and since the door was closed, he would not be able to yell out for assistance because no one would be able to hear him. He indicated that even his roommate at the time was ringing his call bell and no one would come. He indicated that it was not until the next shift when they finally came into his room.
Interview with Registered Nurse 1 on March 13, 2024, at 4:19 p.m. revealed that Resident 1 stated that Nurse Aide 3 came into his room and was rude. He had asked her for his call bell and Nurse Aide 3 would act as if she was going to give the call bell to him and then she would pull the call bell away, so he swore at her. Nurse Aide 3 made the resident mad by placing the call bell away from him, so that he could not use it. She indicated that at the time of her interview with the resident, she was not thinking it was abuse.
Interview with the Nursing Home Administrator on March 15, 2024, at 11:08 a.m. confirmed that the incident between Resident 1 and Nurse Aide 3 was considered abuse per their policy.
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)(j) Resident Rights.
28 Pa. Code 211.12(d)(5) Nursing Services.
| | Plan of Correction - To be completed: 04/11/2024
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the annual re-licensure survey ended on March 15, 2024.
F600 Free from Abuse and Neglect
1. Actions taken for the situation identified:
Observations and assessments revealed no ill effects or injuries Resident 1.
A full investigation was completed, and Nurse Aide 3 has been placed on the Do Not Return list due to poor work performance; however, the facility was unable to substantiate the allegation of abuse. An event report will be filed, including a PB-22 report.
2. How the facility will act to protect residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Facility staff, as well as agency staff, will be re-educated on the facility's policy on abuse and neglect, residents' rights, and the facility policy for following the individualized care plans in place for each resident.
3. System changes and measures to be taken:
The Regional Clinical Nurse Consultant will educate facility managers on properly identifying and investigating allegations of abuse. The Director of Nursing will educate facility staff, including agency staff, on how to properly report concerns, incidents, and allegations timely so that a thorough investigation can be initiated. Concern forms will be reviewed at both Clinical Morning Meeting and the afternoon Stand Down Meeting until resolved. All allegations of abuse will be investigated and reported to the Department of Health per facility policy through the electronic Event Reporting System, and other entities will be notified as required.
4. Monitoring mechanisms to assure compliance:
The Administrator/designee will be responsible for randomly monitoring 24-hour nursing reports, incident reports, and resident concerns (3) times a week for two (2) weeks and once (1) a week for four (4) weeks to ensure allegations of abuse are investigated and reported appropriately. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure quality standards continue to be met.
5. Date Corrective Action will be completed:
Substantial compliance is expected by April 11, 2024.
|
|
