Other·November 28, 2023

§483.12(c) Reporting of Alleged Violations. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. 42 CFR §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. 22 CFR § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § HSC 1418.91 Abuse Reporting (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 10/6/2023, the Department received a facility reported incident (FRI) regarding an allegation of Resident 2 allegedly hit Resident 1 on the right shoulder with a television remote control. On 10/19/2023, an unannounced visit was conducted at the facility. The facility failed to: 1. Implement its abuse policy and procedure (P&P) by failing to report an allegation of abuse for Resident 1 and Resident 2 to the State Survey Agency (SSA) within two hours after being made aware of the allegation. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from further abuse. A review of Resident 1’s Admission Record indicated Resident 1 was a 71-year-old male, was admitted on 4/22/2023, with admitting diagnoses that included dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) and encephalopathy (any brain disease that alters brain function or structure, with potential for symptoms such as declining ability to reason and concentrate, and/or memory loss). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/2023, indicated Resident 1 had severe impairments to his cognition (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception). During a concurrent observation and interview on 10/19/2023 at 10:53 a.m., Resident 1 was observed sitting in the hallway with a staff member seated next to him for supervision. Resident 1 stated he could not recall any altercation happening between himself and any other residents in the facility. Resident 1 was able to state his first name, last name, and the year. Resident 1 nodded his head side to side to indicate a “no” response when asked if he could state where he was or why he was there. A review of Resident 2’s Admission Record indicated Resident 2 was a 65-year-old male, was admitted on 8/31/2023, with admitting diagnoses that included a history of falling, difficulty walking, bilateral primary osteoarthritis (the wearing down of the protective tissue at the ends of bones [cartilage] occurs gradually and worsens over time, resulting in joint pain), and muscle weakness. Resident 2’s Admission Record further indicated Resident 2 was discharged from the facility on 10/18/2023. A review of Resident 2’s MDS, dated 9/2/2023, indicated Resident 2 had moderate impairment to his cognition. The MDS further indicated Resident 2 required one-person physical assistance to move within his bed or transfer between surfaces (e.g., to or from bed, chair, wheelchair, standing position). During a telephone interview on 10/19/2023 at 2:51 p.m., Certified Nurse Assistant (CNA) 2 stated she observed Resident 2 hit Resident 1 with a call light (a device used by a patient to signal his or her need for assistance from professional staff). CNA 2 stated Resident 2 told her Resident 1 had sat on his legs which caused him pain. CNA 2 stated Resident 2 told her this made him upset and led to him hitting Resident 1. CNA 2 stated the altercation occurred on 10/5/2023 in the evening, and stated she notified Registered Nurse (RN) 1 immediately after separating the residents. A review of Resident 1’s medical record, an assessment titled “Change in Condition Evaluation”, dated 10/6/2023, the record indicated the Director of Nursing (DON) was notified on 10/6/2023 that Resident 2 hit Resident 1. The assessment further indicated the altercation occurred on 10/5/2023 in the evening. A review of Resident 2’s medical record, an assessment titled, “Change in Condition Evaluation”, dated 10/6/2023, the record indicated Resident 2 “hit his roommate on the right shoulder”, and further indicated the altercation occurred on 10/5/2023 in the evening. During a telephone interview on 10/20/2023 at 3:26 p.m., RN 1 stated CNA 2 reported the altercation between Resident 1 and Resident 2 to her on 10/5/2023 in the evening. RN 1 stated the altercation was supposed to be reported within two hours, and stated she did not report the altercation to the DON until the next morning, on 10/6/2023. RN 1 stated staff were supposed to report abuse, including resident to resident altercations, within two hours to keep the facility residents safe. RN 1 stated, “They (residents) don’t speak for themselves, so you have to protect them.” A review of the document titled “Report of Suspected Dependent Adult/Elder Abuse” dated 10/6/2023, indicated the altercation between Resident 1 and Resident 2 was reported to the state agency on 10/6/2023 at 10:55 a.m. During an interview on 10/20/2023 at 4:47 p.m., the DON stated the altercation between Resident 1 and Resident 2 occurred on 10/5/2023 in the evening. The DON stated all facility staff were mandated reporters, and stated the altercation should have been reported within two hours. The DON stated reporting abuse was important to protect the facility residents, and stated it was a risk to the residents’ safety if abuse was not reported timely. A review of the facility P&P titled, “Identifying Types of Abuse,” dated 9/2022, indicated abuse toward a resident can occur as resident-to-resident abuse. The P&P further indicated some situations of abuse do not result in observable physical injury or the psychosocial effects of abuse may not be immediately apparent and indicated “other residents may not be able to speak due to a…cognitive impairment, cannot recall what has occurred”. The P&P indicated staff are trained on abuse reporting and investigation. A review of the facility’s P&P titled, “Abuse Investigation and Reporting,” dated 7/2017, indicated “an alleged violation of abuse…or mistreatment…will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse.” The facility failed to: 1. Implement its abuse policy and procedure (P&P) by failing to report an allegation of abuse for Resident 1 and Resident 2 to the State Survey Agency (SSA) within two hours after being made aware of the allegation. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from further abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.