§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.
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Observations:
Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R1). Findings include: Review of facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement. "Abuse," is defined at 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. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology." "Sexual abuse," is defined at as "non-consensual sexual contact of any type with a resident." Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and arthritis (swelling or tenderness in one or more joints). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Continence is coded as a "2". Review of Resident R1's care plan dated 12/4/24, indicated assist with daily hygiene, grooming, dressing, oral care, and eating as needed. During a review of documentation provided by the facility on 5/5/25, at 9:00 a.m. indicated that resident reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R1 indicated that Alleged Perpetrator (AP) Employee E2 was assisting with incontinence care and AP Employee E2, "touched my bottom and kept touching me there" and "I don't want him here anymore". COTA Employee E1 reported incident to supervisor immediately. During a review of documentation provided by the facility on 5/5/25, at 9:30 a.m. revealed that the facility failed to recognize and report this allegation of sexual abuse on 4/24/25, and failed to investigate the alleged sexual abuse. During an interview on 5/5/25, at 11:10 a.m. the Nursing Home Administrator (NHA) stated that the Director of Nursing (DON) was made aware of the allegations on 4/24/25. During an interview on 5/5/25, at 11:15 a.m. the NHA confirmed the facility was unable to provide an investigation for reported abuse allegation from 4/24/25, for Resident R1, and the NHA confirmed that the facility did not report it. During an interview on 5/5/25, at 3:00 p.m. the NHA confirmed that the facility failed to report an allegation of abuse for one of three residents (Resident R1). 28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management 28 Pa Code: 201.18 (b)(1) (e)(1) Management.
| | Plan of Correction - To be completed: 05/28/2025
Corrective Action for Affected Residents: The facility immediately removed AP Employee E2 from resident care duties and initiated a thorough investigation of the allegation made by Resident R1. The allegation was immediately reported to the State Survey Agency and appropriate authorities. A skin assessment was completed for Resident R1, and the resident was assessed by Social Services for any signs of emotional distress. The resident was provided with counseling services, and the care plan was updated to reflect current interventions.
Identifying other Residents having the Potential to be Affected: The Interim Director of Nursing (DON)/designee conducted interviews with alert and oriented residents to identify any other potential incidents of abuse without concern.
Measures put into place or Systemic Changes: The DON/designee will in-service all department managers on abuse reporting requirements, including time frames, as well as: - Recognition of abuse - Immediate reporting requirement - Protection of residents during investigations - Documentation requirements the facility's abuse policy was revised to include a clear reporting protocol and chain of command.
Plan to Monitor Performance: The Administrator/designee will conduct weekly audits of all incident reports and grievances daily for 1 week, weekly for 1 month and monthly for 3 months to ensure proper reporting and investigation of abuse allegations. The DON/designee will conduct random interviews with 10% of alert and oriented residents biweekly for 1 week, weekly for 1 month and monthly for 3 months to ensure no unreported allegations exist. The Administrator will review all abuse allegations daily to ensure proper reporting timeframes are met.
The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months. The QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained.
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