Health inspection·June 28, 2023

HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within two hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On April 4, 2023, at 12:16 p.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse. It was determined that based on interview and record review, the facility failed to report an allegation of physical abuse involving Patient 1 and Patient 2 to the State Survey Agency (SSA) within 24 hours. The facility was made aware of the alleged physical abuse involving the two patients on March 30, 2023 and did not report the alleged incident to the SSA until April 4, 2023 (5 days after the incident occurred). This failure increased the risk for further abuse due to delayed notification to respond and advocate on behalf of Patient 1 and Patient 2. A review of Patient 1's medical record indicated the patient was admitted on March 9, 2023, with diagnoses which included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows), schizoaffective disorder (chronic mental health condition that involves symptoms of disturbances in thought and mood swings), and dementia (chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Patient 1's "History and Physical," dated March 10, 2023, indicated she did not have the capacity to understand and make decisions. A review of Patient 1's record titled, " SBAR (Situation, Background, Assessment, Recommendation) Communication Form," dated March 30, 2023, at 3:14 p.m.; indicated," ...PER REPORT BY CARE STAFF RESIDENT (Patient 1) GRABBED AND PULLED THE HAIR OF ANOTHER RESIDENT (Patient 2) IN THE HALLWAY..." A review of Patient 2's medical record indicated the patient was admitted to the facility on March 15, 2023, with diagnoses which included COVID 19 (contagious respiratory disease caused by the SARS-CoV-2) and pathological fracture (broken bone caused by disease, often by the spread of cancer to the bone). A review of Patient 2's, "SBAR Communication Form," dated March 30, 2023, at 3 p.m., indicated," ...Got her (Patient 2) hair pulled and got scratches by another resident (Patient 1)..." On April 4, 2023, at 1:53 p.m., during interview, the Director of Nursing (DON) verified that on March 30, 2023, Patient 1 grabbed Patient 2 by the hair. On April 4, 2023, at 3:08 p.m., during interview, the facility Administrator (ADM) stated the incident involving Patient 1 and Patient 2 occurred on March 30, 2023, at approximately 3 p.m. The ADM stated he sent instruction via text to the Social Service Director (SSD) on March 30, 2023, at 3:54 p.m., to fax the facility reported incident involving the two patients (Patients 1 and 2) to the SSA. During the interview, the ADM checked his text messages, and he stated the text message to the SSD on March 30, 2023, did not go through. He stated the report on the incident had not been faxed to the SSA. A review of the facility report on the alleged physical abuse involving Patients 1 and 2, indicated the report was received by the SSA on April 4, 2023 (5 days after the incident occurred). A review of the facility policy and procedure title, " Elder/Dependent Adult Abuse," revised December 17, 2019, indicated,"...Jurisdiction in Long-Term Care Facilities...Phone/Fax All alleged violations- Immediately but not later than 2 hours- involves any type of alleged abuse... If reportable, document a written abuse report on SOC 341 (from the State of Department of Social Services) ... and submit to the appropriate agencies..." It was determined that based on interview and record review, the facility failed to report an allegation of physical abuse involving Patient 1 and Patient 2 to the SSA within 24 hours. The facility was made aware of the alleged physical abuse involving the two patients on March 30, 2023; and did not report the alleged incident to the SSA until April 4, 2023 (5 days after the incident occurred). This failure increased the risk for further abuse due to delayed notification to respond and advocate on behalf of Patient 1 and Patient 2. This violation had a direct or immediate relationship to the health, safety, or security of all patients.