Other·August 5, 2022

F609 CFR §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 patient 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. T22 Section 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 6/17/2022, the State Survey Agency (the Department) made an unannounced visit to the facility to investigate a complaint regarding patient abuse. The facility failed to thoroughly investigate and failed to twice report Patient 1's allegation of sexual abuse to the Department (Licensing and Certification Program) not later than 2 hours after becoming aware of Patient 1's allegation. This violation resulted in late reporting of an allegation of sexual abuse and had the potential for Patient 1 to experience further abuse. A review of Patient 1's Admission Record indicated Patient 1, a 37-year-old female, was admitted to the facility on 5/21/2022. Patient 1's diagnoses included hypoxic-ischemic encephalopathy (is a non-specific term for brain dysfunction caused by a lack of blood flow and oxygen to the brain), muscle wasting, and legal blindness. A review of Patient 1’s Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 5/27/2022 indicated the patient had moderately impaired cognition (ability to understand), and required limited assistance to total dependence from one to two staff with activities of daily living. During an interview on 6/17/2022 at 12:15 p.m. the Director of Nursing (DON) stated Patient 1 went to the hospital on 6/14/22, and upon return to the facility on 6/15/22, Patient 1 told the paramedics that she was touched on the breasts by a male staff at the facility. The DON stated she was still investigating, and interviewing staff assigned to Patient 1. The DON stated there was no staff by the name Patient 1 had alleged touched her. During an interview on 6/17/2022 at 12:25 p.m., the Quality Assurance staff (QA) stated the facility's own investigation was ongoing. The QA staff stated Patient 1 initially reported on 5/27/22 to Charge Nurse 1 (CN 1 that a male staff member had touched her breast four days prior (5/23/22). The QA staff stated facility reviewed the staff assignment, investigated, and informed Patient 1 that there was no staff by that name, nor a male staff had been assigned to Patient 1. The QA staff stated the allegation was never reported to the Department (Licensing and Certification Program) because the alleged staff does not exist. The QA staff stated Patient 1 was transferred to General Acute Care Hospital (GACH) on 6/14/22 for chest pain. Patient 1 told the paramedics while being transported that 1 to 2 months ago, her breast was touched by one of the facility's staff. The QA staff stated the facility was made aware that Patient 1 was still making the allegation when the police department (PD) came on 6/15/22 at approximately 6:30 a.m., to address the allegation. Patient 1 was still at the GACH at that time and the facility notified the Department on 6/16/22. The QA staff acknowledged the facility was aware of the allegation on two separate occasions but did not report either allegation within 2 hours. During an interview on 6/17/2022 at 12:50 p.m., Patient 1 stated she asked the male staff for his name, and he gave it to her. Patient 1 thought the male staff was responding to the call light to her request for cold water. Patient 1 stated the male staff never gave her water and instead touched her breast. Patient 1 stated she yelled for help but there was no response. Patient 1 stated she didn't report the incident at that time. Patient 1 stated she was afraid no one would believe her. Patient 1 stated she reported to her husband first, the facility second and then reported it to the paramedics. During an interview on 6/17/22 at 3:30 p.m. with the QA staff, the DON, and the Administrator, all verbalized they did not report Patient 1’s allegation of abuse to the Department within 2 hours after the first (5/27/22) and second (6/14/22) allegations were made. The facility notified the Department on 6/16/22. During a telephone interview on 6/23/2022 at 3:55 p.m. the DON stated on 5/23/2022, there was a male certified nurse assistant assigned to Patient 1 on the 3 p.m.-11 p.m. shift. A review of the facility's fax transmittal indicated the facility reported the allegation to the Department on 6/16/22 at 4:20 p.m. A review of the facility's Policy and Procedures dated 4/2021 titled, "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating," indicated allegations of abuse must be reported within 2 hours. The facility failed to thoroughly investigate and failed to twice report Patient 1's allegation of sexual abuse to the Department not later than 2 hours after becoming aware of Patient 1's allegation. As a result, this violation resulted in late reporting of an allegation of sexual abuse and had the potential for Patient 1 to experience further abuse. The above violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.