§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 records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse/neglect for one of three residents (Resident R10).
Findings include:
Review of the facility policy "J-5-O Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property" dated 1/8/24, indicated to assure a timely, thorough, and objective investigation of all allegations of abuse, neglect exploitation, mistreatment, or misappropriation of resident property. The Investigation Statement form should include a graphic description if physical abuse is suspected. Be sure to include a description of the scene, positioning of resident and staff, time, nature of injury, etc.
Review of the admission record indicated Resident R10 was admitted to the facility on 8/24/22.
Review of Resident R10's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/7/24, indicated the diagnoses of high blood pressure, heart failure (the heart doesn't pump blood as well as it should), and Parkinson's Disease (disorder of the nervous system that results in tremors).
Review of Resident R10's incident report dated 1/6/24, at 8:00 p.m. indicated resident noted with a skin tear to right lower leg as he was being readied for bed. A trickle of bright red blood present, stopped with slight pressure.
Review of facility provided Risk Management Report dated 1/6/24, indicated Nurse Aides (NA) Employee E3 and Employee E4 reported to Registered Nurse (RN) Employee E5 that they noticed a skin tear on Resident R10's right lower leg when getting him ready for bed.
Review of NA Employee E3's Investigation Statement dated 1/6/24, indicated right lower leg skin tear was noted when getting client ready for bed.
Review of NA Employee E4's Investigation Statement dated 1/6/24, indicated "Pulled down pants, skin tear left lower leg".
Review of Resident R10's second incident report dated 1/24/24, at 8:00 p.m. indicated during evening care the staff observed a horizontal skin tear to resident's right great toe at the bottom of the toe.
Review of facility provided Risk Management Report dated 1/24/24, indicated NA Employee E6 got RN Employee E7 to further assess Resident R10. Resident noted to have a cut to the bottom of the right great toe. Moderate amount of bleeding.
Review of NA Employee E6's Investigation Statement dated 1/24/24, indicated "I was getting resident ready for bed. I took his sock off. His toe started to bleed".
Review of RN Employee E7's Investigation Statement dated 1/24/24, indicated NA Employee E6 got RN Employee E7 to further assess Resident R10. Resident noted to have a cut to the bottom of the right great toe. Moderate amount of bleeding.
Interview with the Director of Nursing (DON) on 2/14/24, at 1:00 p.m. indicated that it was not noticed that both injuries occurred during undressing the resident and that normally the DON would interview employees until finding the employee who last observed the skin intact. The Director of Nursing further indicated that the facility failed to include a description of the scene or positioning of resident and staff at the time.
Interview with the Director of Nursing on 2/14/24, at 2:10 p.m. indicated there was not a thorough investigation completed, and the only witness statements obtained were from staff involved at the time, that the facility failed to fully investigate (interviewing all potential witnesses and to interview other staff members who had contact with Resident R10), alleged allegation of abuse/neglect for one of three residents (Resident R10).
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.12 (d) (1) Nursing services.
| | Plan of Correction - To be completed: 03/25/2024
Assuming for the sake of this discussion, the validity of the deficiencies noted in the Department of Health's Statement of Deficiencies Report to St. Barnabas Nursing Home, Inc. for the Survey ending February 16, 20243, which St. Barnabas does not admit, we offer the following Plan of Correction. Nothing contained in the Plan of Correction shall/should be deemed an admission, either expressed or implied, on the part of St. Barnabas, Inc. as to the validity of the deficiencies noted in the report.
Resident R-10, staff was interviewed a second time to provide more description of what occurred during being readied for bed. Interviews resulted in no perpetrator identified and no abuse suspected. All residents with potential incidents, that require investigation for a source/cause, will include comprehensive description of the scene, actions and/or findings. All nursing staff will be educated on the detailed witness statements required and what will be needed to complete future investigations. The Interdisciplinary team will review each incident investigation completed by the Director of Nursing to ensure and provide a rounded and thorough investigation. The Administrator or designee will audit all incidents for thorough and descriptive investigations statements and results; weekly for one month, bi-weekly for one month and monthly thereafter. All results will be reviewed at the QAPI meeting.
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