Health inspection·November 23, 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. §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. On 10/11/2022 at 8 a.m., an unannounced recertification survey was conducted. The facility failed to: Report Resident 72’s verbal abuse incident that required a room change due to resident-to-resident incompatibility. Adhere to its policy and procedure and investigate the verbal abuse incident and report to the State Survey agency within 24 hours. As a result, there was a delay in the State Agency’s investigation of the abuse and Resident 72 felt unsafe and threaten. During an interview on 10/13/2022 at 10:30 a.m., with Resident 72, while in his room, Resident 72 stated he had a problem with his previous roommate that require a room change. Resident 72 stated the roommate (Resident 122) was calling him names, a sex offender and made a gesture as if he had a gun. Resident 72 stated Resident 122 punched his shoulder. Resident 72 stated he did not feel safe in the room with Resident 122 and felt his life was threatened. During a review of Resident 72’s Admission Record (face sheet), the face sheet indicated Resident 72, a 46 year-old male, was admitted to the facility on 10/10/2022. Resident 72's diagnoses included chronic obstructive pulmonary disease ([COPD], refers to a group of diseases that cause airflow blockage and breathing-related problems), hypertension (high blood pressure) and Type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as fuel). During a review of Resident 72’s History and Physical Examination (HPE), dated 10/11/2022, the HPE indicated Resident 72 had the capacity to understand and make decisions. During a concurrent interview and record review on 10/13/2022 at 10:35 a.m., with the registered nurse supervisor (RNS). The RNS stated Residents 72 and 122 were incompatible roommates on the day of admission and Resident 72 had to be moved to another room. Resident 72’s clinical records (nursing progress notes) indicated there was no documented evidence of any physical and/or verbal altercations between Residents 72 and Resident 122. There was also no documentation indicating Resident 72’s room was changed or why it had to be changed. During an interview on 10/13/2022 at 10:55 a.m., with Resident 122, Resident 122 stated he had a roommate (Resident 72), who was admitted (10/10/2022) to his room, but was moved to another room the same day (10/10/2022). Resident 122 stated he did not hit Resident 72, but he admitted to cursing at Resident 72. During a review of Resident 122’s Admission Record (Face Sheet), the Face Sheet indicated Resident 122, a 58 year-old male, who was admitted on 9/30/2022 with diagnoses that included paranoid schizophrenia (characterized by delusions and hallucinations [debilitating symptoms which blur the line between what is real and what is not, making it difficult for the person to lead a typical life), bipolar disorder (a mental condition marked by alternating periods of elation and depression), and anxiety disorder. A review of Resident 122’s care plan, dated 10/4/2022 and titled, “Mood Swings” the care plan indicated Resident 122 had a history of agitation, with yelling and screaming at others due to his diagnoses of bipolar disorder and schizophrenia. A review of another care plan dated 10/4/2022 and titled, “Poor Coping Ability,” the care plan indicated Resident 122 had behaviors of throwing objects, shouting, and slamming doors. During a concurrent interview and review of Resident 72’s clinical records on 10/13/2022 at 11:55 a.m., with the Social Service Director (SSD), the SSD stated she was aware of the verbal abuse incident between Residents 72 and Resident 122. The SSD stated Resident 122 was using foul language toward Resident 72. The SSD stated the two residents (Residents 72 and 122) were incompatible and a room change was initiated. Resident 72’s clinical record indicated there were no documentation on the social services notes, interdisciplinary notes, and/or physician’s orders for a room change related to Residents 72 and 122’s incompatibility regarding verbal exchange of foul words. During a subsequent interview on 10/14/2022 at 7:55 a.m., with Resident 122, Resident 122 stated he did curse out Resident 72 and the administrator (ADM) asked him questions about the abuse incident on 10/13/2022. Resident 122 stated the staff did not question him about the abuse incident until 10/13/2022 (three days after the incident occurred). During an interview on 10/14/2022 at 9:35 a.m., with the SSD, the SSD stated Resident 72 signed out against medical advice (AMA) after talking with the police regarding the abuse incident. The SSD stated the failure to recognize abuse may leave the resident feeling ignored. During a concurrent interview and review of Resident 72’s clinical record on 10/14/2022 at 10:35 a.m. with the RNS, the RNS stated she failed to report the incident timely to the abuse coordinator (ADM), Ombudsman, or police because she determined the incident was not abuse. The RNS acknowledged the roommate incompatibility incident was not documented on a change of condition, incident report, or nursing progress notes. The RNS stated the incident was not determined to be abuse, but roommate incompatibility, which was not documented. During an interview on 10/14/2022 at 2:02 p.m., and subsequent interview on 10/14/2022 at 12:27 p.m., with the ADM, the ADM stated he understood the regulation regarding abuse reporting was within 24 hours. The ADM stated, “If we do not report abuse in a timely manner, abuse can happen again and may affect the residents.” During a review of the facility’s policy and procedure (P/P) titled, “Abuse Reporting and Prevention” with a revision date of 2/2022, the P/P indicated the purpose of the policy was to ensure resident’s rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect, abuse and including injuries of unknown sources, unusual occurrences, and unauthorized use of resident property. The P/P indicated a resident-to-resident altercation should be reviewed as a potential situation of abuse. When either or both residents have a cognitive impairment or mental disorder it does not automatically mean that an abuse did not occur. If during the investigation, it is determined the resident actions were “willful” or deliberate then abuse has occurred. The P/P indicated verbal abuse was the use of written, oral, or gestured language that was willfully with the use of derogatory or disparaging terms regardless of the resident’s age, ability to comprehend, or disability. The P/P indicated abuse reporting should occur for all alleged violations immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. The facility failed to: Report Resident 72’s verbal abuse incident that required a room change due to resident-to-resident incompatibility. Adhere to its policy and procedure and investigate the verbal abuse incident and report to the State Survey agency within 24 hours. As a result, there was a delay in the State Agency’s investigation of the abuse and Resident 72 felt unsafe and threaten. These violations had a direct relationship to the health, safety, or security of Resident 72.