Other·December 5, 2022

F607 §48(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) 3.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. [§483.12(b)(4) will be implemented beginning November 28, 2019 (Phase 3)] On 11/7/22 at 8:30 a.m., an unannounced recertification survey was conducted at the facility, during the recertification survey, an entity reported incident regarding Quality of Care/Treatment was also investigated. The facility failed to implement its written policies and procedures for reporting and investigation of allegations of abuse for Patient 1 when Patient 1's abuse allegation was not reported and investigated. These failures had the potential to result in the abuse recurrence to patients in the facility. Review of Patient 1's clinical record indicated she was an elderly female, admitted on 1/19/22 with the diagnoses of Alzheimer's disease (progressive disease that destroys and other important mental functions), dementia (loss of memory) with behavioral disturbances, chronic obstructive pulmonary disease (COPD, lung disease that causes obstructed airflow), history of transient ischemic attack (TIA, temporary blockage of blood flow to the brain), generalized muscle weakness, chronic atrial fibrillation (irregular heartbeat), presence of prosthetic heart valve (designed to replicate the function of native valves by maintaining unidirectional blood flow) and history of falling. Review of Patient 1's Minimum Data Set (MDS, an assessment tool), dated 7/16/22, indicated she had a Brief Interview for Mental Status (BIMS) score of 9 (a score of 8 to 12 indicates moderate cognitive impairment). Review of Patient 1's nursing notes, dated 7/8/22, indicated Patient 1 alleged that a staff member grabbed both her arms on the night of 7/4/22 and there was a discoloration to Patient 1's right forearm. Further review of Patient 1's clinical record indicated there was no documentation indicating the facility investigated Patient 1's allegation of abuse. There was also no documentation indicating the facility reported Patient 1's allegation to the necessary entities. During an interview with hospice registered nurse F (HRN F) on 11/9/22 at 9:40 a.m., she verified there was an allegation of abuse made by Patient 1 a few months ago. During an interview with the director of nursing (DON) on 11/9/22 at 4:30 p.m., the DON verified that the allegation of abuse made by Patient 1 in July 2022 was never investigated and was never reported to local, state and federal agencies. The DON further stated there was no investigation report for Patient 1's abuse allegation. Review of the facility's "Nursing Services Policy and Procedure Manual for Long-Term Care: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised April 2021, indicated, "All reports of resident abuse, including injuries of unknown origin, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies, as required by current regulations and thoroughly investigated by facility management. Findings of all investigations are documented and reported." "If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as, within two hours of an allegation involving abuse or result in serious bodily injury; or within twenty-four hours of an allegation that does not involve abuse or result in serious bodily injury. All allegations are thoroughly investigated. The administrator, or his/her designee, provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation." The facility failed to implement its written policies and procedures for investigation and reporting of allegations of abuse for one of three sampled patients (Patient 1) when Patient 1's abuse allegation was not investigated and reported. These failures had the potential to result in the recurrence of abuse that could affect the health, welfare and rights of the patients residing in the facility. This violation had a direct or immediate relationship to the health, safety, or security of the patients.