Health inspection·November 14, 2022

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §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.

F610. (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/13/2022 the Department of Public Health (DPH) received a complaint alleging a certified nursing assistant (CNA 1) was verbally and physically aggressive with a disabled Resident 1 a 41-year-old male, and Resident 1 did not feel safe in the facility. On 9/14/2022, at 10:30 a.m., an unannounced visit was made to the facility to investigate the allegation of abuse. The facility failed to: 1. Ensure the facility’s administrator (ADM) and/or designee, who was aware of Resident 1’s allegation of abuse, reported an allegation of abuse immediately but no longer than two hours after the allegation was made to the DPH and the Ombudsman. 2. Ensure the administrator removed the alleged perpetrator, CNA 1, from the facility, until the investigation of the abuse allegation was completed. 3. Ensure the facility implemented its policy and procedure (P/P) titled “Abuse Reporting and Prevention,” on reporting and investigating allegation of abuse. These failures resulted in the DPH being unaware of CNA 1’s alleged abuse to Resident 1with the potential for continued abuse, against made Resident 1 feel unsafe in the facility, and had the potential to impede the Department’s investigation. During a review of Resident 1's Admission Records (Face Sheet[FS]), the FS indicated Resident 1 was admitted to the facility on 5/17/2022 with diagnoses including right lower leg cellulitis (a bacterial skin infection causing redness, swelling and pain), surgical removal of fifth toe and part of the bony area of the foot, diabetes mellitus (disease in which the body is not able to regulate and process sugar absorption), hemodialysis (treatment to filter wastes, salts, and fluid from blood for those with kidney failure), and left below knee amputation (surgical removal). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 8/26/2022, the MDS indicated Resident 1’s cognitive skills (a mental process of acquiring knowledge and understanding) for daily decision making were intact. The MDS indicated Resident 1 required limited assistance from staff for bed mobility, transfers, toilet use and personal hygiene, and an extensive physical assistance from staff for bathing. The MDS indicated Resident 1 used a wheelchair to move around the facility and had limb (leg) prosthesis (an artificial limb that replaces a missing body part). During a review of Resident 1's Nursing Progress Notes (NPN), dated 9/11/2022 and timed at 8:25 a.m., the NPN indicated Resident 1 reported CNA 1 was threatening to hit him, but other CNA stopped CNA 1 and pulled CNA 1 outside of the building to deescalate the situation. The NPN indicated Resident 1 called the local police department after facility staff told Resident 1 “nothing could be done at this time.” During an interview with the ADM on 9/20/2022 at 3:49 p.m., the ADM stated he did not report the alleged incident to the DPH, or Ombudsman and he should have reported the allegation no later than two hours after receiving the allegation to the DPH, the Ombudsman, and the law enforcement agency. During a review of the facility’s Incident Report (IR), dated 9/11/2022, the IR had no documentation to indicate the facility reported the alleged abuse to the Department; that CNA 1 was removed from the facility pending investigation completion, or that the Department was notified of the conclusion to the facility’s investigation. During a concurrent observation and interview with Resident 1 on 9/14/2022 at 1:31 p.m., Resident 1 stated on 9/11/2022 CNA 1 was running towards him in an angry manner. Resident 1 stated he feared for his life, and he should not be made to feel that way. During a concurrent interview and record review with the Director of Nursing (DON) on 9/20/2022 at 3:31p.m., the DON stated CNA 1 was immediately separated from Resident 1 and assigned to the South side of the facility the day of the incident. The DON stated Resident 1’s room was on the North side of the facility. The DON stated CNA 1 continued to work on the day Resident made the abuse allegation (9/11/222) and the following day but was assigned to residents who were on the South side of the facility. The DON provided the Assignment Sheets for 9/12/2022 which indicated CNA 1’s assignment on the South side of the facility and signature. The DON acknowledged they should have sent CNA 1 home right away while investigating the allegation of abuse. The DON also stated any alleged or suspected abuse must be reported to the DPH, the ombudsman, and the law enforcement agency. During a review of facility's P/P, titled, “Abuse Reporting and Prevention,” revised 8/2016, the P/P indicated the administrator, or his/her designee will report each alleged abuse to the Ombudsman office and the Department of Public Health immediately. A written report must follow within 24 hours to either the local Ombudsman or local law enforcement agency. When an incident involving the health, welfare, or safety of the residents, including suspected abuse are reported if the suspected abuser is an employee, remove the employee immediately from the care of all residents. The facility failed to: 1. Ensure the facility’s administrator (ADM) and/or designee, who was aware of Resident 1’s allegation of abuse, reported an allegation of abuse immediately but no longer than two hours after the allegation was made to the DPH and the Ombudsman. 2. Ensure the administrator removed the alleged perpetrator, CNA 1, from the facility, until the investigation of the abuse allegation was completed. 3. Ensure the facility implemented its policy and procedure (P/P) titled “Abuse Reporting and Prevention,” on reporting and investigating allegation of abuse. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.