§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 upon review of facility policy and procedure and clinical record review, it was determined the facility failed to report to the State agency an allegation of abuse for one of 24 residents reviewed (Resident 28).
Findings include:
Review of facility policy and procedure titled Abuse, Neglect or Exploitation, revised 10/24/2022, revealed "For Skilled Facilities covered under the Elder Justice Act an individual must report any alleged violations of abuse OR if there was serious bodily injury the facility MUST report the allegation to the DOH IMMEDIATELY BUT NO LATER THAN 2 HOURS AFTER THE ALLEGATION IS MADE. For those allegations that are neglect, exploitation, misappropriation of resident property, or mistreatment that do NOT result in serious bodily injury, the facility must report the allegation no later than 24 hours."
Review of Resident 28's clinical progress notes dated December 2, 2023, revealed "CNA's following care plan and two assist with all care. After resident received a bed bath turned to female CNA and stated he is being rough with me. Female CNA reported that she had been present and assisting throughout care. Observed no such behavior. Nurse provided privacy and asked resident the following questions: How was your bed bath? replied ok. Do you feel clean? Replied yes. Are you having any pain or discomfort? replied no. Do you feel safe? replied yes. Made supervisor aware. Revisited resident. Asked the following: Are you ok? replied yes and smiled. Are you happy with the care and bed bath you received? Replied "yes" Are you having any pain or discomfort? Replied no and smiled. Asked if resident need to talk about anything? replied "no, I'm okay". Are you ok with the people that gave you a bed bath? Yes. Do you feel safe? Replied "yes". Supervisor updated."
Review of facility documentation and clinical record failed to reveal evidence the above allegation of abuse was reported to the State agency.
Interview with the Nursing Home Administrator and Director of Nursing on February 15, 2024, at 11:00 a.m. confirmed the above allegation was not reported to the State Agency.
28 Pa. Code 201.18(a)(b)(1)(2)(g)(1) Management
| | Plan of Correction - To be completed: 03/26/2024
1. Resident 28 was assessed for injury by RN, no injuries noted. 2. Current resident progress notes will be reviewed for any reports of concern. In the event any are found, they will be reported timely, and full investigation will take place. 3. Health Center staff will be educated by the NHA or designee on Resident Rights, and Abuse Neglect or Exploitation policy, including reporting requirements. Moving forward, the Facility will report any allegations of abuse as per the Facility policy and DOH regulations within the required time frames. The Facility Administration will conduct any investigations and report the findings to DOH and/or any other regulatory entity as required by law or regulation. 4. DON or designee will review the clinical progress notes daily for any allegations of abuse or neglect, and ensure that appropriate notification had occurred for one week. These audits will continue once weekly for 4 weeks, and 5 random days monthly x 2 months. The results of these audits will be forwarded to the Quarterly Quality Assurance meetings for review and recommendations.
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