Health inspection·November 2, 2022

F609 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §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. § 72523(a) 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 9/15/2022 the Department of Public Health (DPH) received a Facility Reported Incident (FRI) alleging a male employee sexually assaulted Resident 1. On 9/16/2022, at 12:25 p.m., an unannounced visit was conducted to the facility to investigate the allegation of sexual abuse. Upon investigation, it was determined the allegation was reported to the facility on 9/14/2022 around 10:40 p.m. but was not reported to the Department until 9/15/2022 at 9:20 a.m. The facility failed to ensure: An allegation of sexual abuse was reported to the DPH within the required time frame of two hours. As a result, there was a delay in the Department’s investigation of the allegation of sexual abuse, the potential for pertinent data loss and/or information being forgotten, and the potential of continued sexual abuse. During a review of Resident 1’s Admission Record, the record indicated Resident 1 was initially admitted to the facility on 1/8/2021 and readmitted on 3/27/2022 with diagnoses including generalized muscle weakness and Parkinson’s disease (a disorder of the central nervous system that affects movement, often including tremors). During a review of Resident 1’s History and Physical (H&P) dated 3/26/2022, the H&P indicated Resident 1 was able to make medical decisions. During a concurrent interview and record review on 9/16/2022 at 12:30 p.m., with the Administrator (ADM), a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was reviewed. The SOC 341 indicated the date of completion was 9/15/2022. The ADM stated, he completed the SOC 341 on 9/15/2022 and faxed it to the Department on the same day at 4:27 p.m. The ADM stated the allegation of sexual abuse was initially reported via telephone to the Department on 9/14/2022 at 10:42 p.m., however the ADM was not able to provide any records of said phone call. During a concurrent interview and record review on 9/16/2022 at 3:05 p.m., with Registered Nurse Supervisor 1 (RN 1), Resident 1’s Change of Condition [COC]/Interact Assessment Form [SBAR], (a concise way to communicate any significant changes of conditions in a resident’s functional or psychosocial health), dated 9/14/2022 and timed at 4:37 p.m., was reviewed. The SBAR indicated on 9/14/2022 at 1 p.m., Resident 1 reported an Asian male touched her private area, but she could not remember who he was. RN 1 confirmed, the SBAR did not indicate the Department was notified. According to the State Operation Manual for Skilled Nursing (Rev. 173, 11-22-17) CFR §483.12(c)(1) the facility must ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made. During a concurrent interview and record review on 9/22/2022 at 2:19 p.m., with the ADM, the facility’s undated policy and procedure (P/P) titled, “Abuse Allegation,” was reviewed. The P/P indicated an employee who identifies suspected abuse committed against an individual who is a resident must report the incident to License and Certification Program (L&C) within 24 hours. The ADM confirmed the policy did not indicate reporting within the required 2-hours period. The facility failed to ensure: An allegation of sexual abuse was reported to the DPH within the required time frame of two hours. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.