Other·January 18, 2023

F610 §483.12(c) Investigate/Prevent/Correct Alleged Violation. 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)(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. § 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. On 11/17/2022, the Department received a complaint reporting a concern of the alleged sexual abuse of Resident 1 due to a routine urinalysis that resulted positive for trichomoniasis (a sexually transmitted infection caused by a parasite). On 11/18/2022, an unannounced visit was conducted at the facility. Resident 1 was transferred to a general acute care hospital (GACH) on 11/14/2022 due to bleeding observed in the resident’s adult brief. On 11/15/2022, the GACH Social Worker called the facility and spoke with the Director of Nursing (DON) regarding the concerns/potential abuse allegations made by night shift nurse and Medical Doctor (MD). The facility failed to: 1. Report an allegation of sexual abuse for Resident 1 to the Department of Public Health, Licensing and Certification (DPH L&C). 2. Conduct a thorough investigation for allegation of sexual abuse and provide written conclusions of their investigation for Resident 1. As a result, the investigation of the sexual abuse allegation was delayed and potentially increased the risk for Resident 1 and other residents in the facility to be sexually abused. During a review of Resident 1’s Admission Record (face sheet), the face sheet indicated Resident 1, was an 85 year old female, who was originally admitted to the facility on 6/1/2019 and was readmitted on 11/13/2022 with the diagnoses including urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), adult failure to thrive (a decline seen in older adults resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression, and decreasing functional ability), and dementia (condition characterized by impairment of brain functions, such as memory loss and judgement). During a review of Resident 1’s History and Physical (H&P), dated 5/3/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 8/26/2022, the MDS indicated Resident 1’s cognition was severely impaired and did not have the capacity to understand and make decisions. The MDS indicated Resident 1 required extensive assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1’s Change of Condition ([COC] a sudden clinically important deviation from a patient’s baseline in physical, cognitive behavioral, or functional domains), dated 11/14/2022, the COC indicated Resident 1 had vaginal bleeding times three episodes and primary care clinician ordered to transfer Resident 1 to the General Acute Care Hospital (GACH) for further evaluation. During a record review of the GACH records, dated 11/15/2022, the GACH records indicated Resident 1’s had presented to the Emergency Room (ER) on 11/14/2022 due to blood in the urine. The records indicated Resident 1’s urinalysis resulted positive for trichomonas (a sexually transmitted infection caused by a parasite). During a record review of the GACH records, dated 11/15/2022, the GACH records indicated Resident 1’s night nurse filed an Adult Protected Services ([APS] agency that provides social services to abused, neglected, or exploited older adults) report due to possible abuse. The GACH records indicated Resident 1’s nurse and primary care physician were concerned for Resident 1 being discharged back to the facility. The GACH records indicated the Social Worker (SW) called the facility on 11/15/2022, at 11:04 a.m., to obtain collateral information (information gathered from a patient’s known contacts) and spoke with the Social Services Director (SSD). During a record review of the GACH records, dated 11/15/2022, the GACH records indicated the SW called the facility and spoke with the Director of Nursing (DON) regarding the concerns/potential abuse allegations made by night shift nurse and Medical Doctor (MD). The GACH records indicated the DON stated it was unclear if Resident 1’s bleeding in her adult brief was in her urine and due to her UTI. The GACH records indicated that due to the contact made with the DON and APS to conduct an investigation from their standpoint, Resident 1 would return to the facility. During an interview on 11/23/2022, at 2:00 p.m., with the Administrator (ADM), the ADM stated trichomonas was a sexually transmitted disease. The ADM stated Resident 1 was a long-term resident of the facility since 2019. During an interview on 11/23/2022, at 4:40 p.m., with the DON, the DON stated he spoke with the GACH SW on 11/15/2022 and told the SW that Resident 1 was transferred to the hospital for further evaluation due to the bleeding in her brief. The DON stated the SW told him sexual abuse was being ruled out due to the nature of why Resident 1 was sent to the hospital. The DON stated the sexual abuse allegation for Resident 1 should have been reported to the Department of Public Health (DPH) and he did not know why it was not reported. The DON stated the police was called and came on 11/19/2022 to speak with Resident 1. The DON stated there was no police case number given to the facility. The DON stated the facility’s P&P for reporting abuse indicated the investigation should have been completed within five days of the sexual allegation and the investigation report should have been submitted by 11/21/2022. The DON stated he was not sure why the investigation was not completed on time. During an interview on 11/23/2022, at 4:58 p.m., with the Administrator (ADM), the ADM stated the sexual abuse allegation should have been reported. The ADM stated it was his responsibility and his mistake that he did not report the suspicion of sexual abuse to the DPH. The ADM stated, “to be honest, the facility did not call the police, the police showed up on Saturday”, 11/19/2022 and he was not sure who sent the police to the facility. The ADM stated maybe it was the hospital. The ADM stated the Ombudsman (an advocate for residents of nursing homes, board and care homes, and assisted-living facilities) was not made aware of the sexual abuse allegation for Resident 1 and they (Ombudsman) should have been. The ADM stated it was important to report a sexual abuse allegation to the DPH, the police and the Ombudsman, to investigate the allegation, and prevent the risk of Resident 1 and other residents being abused. The ADM stated the facility began the investigation for the sexual abuse allegation regarding Resident 1 on 11/16/2022 and it should have been completed on 11/21/2022 according to the facility’s P&P for reporting abuse. The ADM stated it was important to report a sexual abuse allegation to the DPH, the police and the Ombudsman and to investigate the abuse allegation to prevent the risk of Resident 1 and other residents being abused. During a review of the facility’s P&P titled, “Abuse Investigation and Reporting”, dated as revised 7/2017, the P&P indicated, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident’s Representative (Sponsor of Record); d. Adult protective Services; e. Law enforcement officials; f. The resident’s attending physician; and g. The facility medical director. The P&P further indicated, “An alleged violation of abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury.” The P&P indicated, “The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.” The facility failed to: 1. Report an allegation of sexual abuse for Resident 1 to DPH, L&C. 2. Conduct a thorough investigation for allegation of sexual abuse and provide written conclusions of their investigation for Resident 1. As a result, the investigation of the sexual abuse allegation was delayed and potentially increased the risk for Resident 1 and other residents in the facility to be sexually abused. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security for Resident 1.