Other·June 11, 2021

F610 §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. § 72521. Administrative Policies and Procedures. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. On 3/17/2021, an unannounced visit was made to the facility to investigate an abuse allegation. The facility failed to implement its abuse policy for Resident 1. On 2/9/2021, Resident 1 alleged abuse when the Registered Nurse Supervisor covered Resident 1’s mouth with her hand. The facility failed to report to the Licensing State Agency (SA, the Department) within the 2 -hour timeframe when they learned about the allegation on 3/4/2021. The allegation was reported to the Department on 3/8/2021. As a result, Resident 1 became angry and upset. The investigation of the abuse was delayed and placed Resident 1 at risk for further abuse. A review of Resident 1's Admission Record indicated the facility readmitted the resident on 1/10/2020, with diagnoses including paranoid schizophrenia (a mental disorder in which people interpret reality abnormally) and osteoarthritis (a condition that causes the cartilage in a joint to break down). A review of Resident 1's History and Physical dated 1/27/2021, indicated Resident 1 had the capacity to understand and make decisions. During an interview on 3/17/2021 at 1:38 p.m., Resident 1 stated while she was talking to the Registered Nurse (RN) Supervisor on 2/9/2021, the RN Supervisor used her hand to cover Resident 1’s mouth. Resident 1 stated, “I told her (RN Supervisor) I don’t want to talk to her then she (RN Supervisor) put her hand up on my mouth and covered my mouth. I was so angry and upset.” Resident 1 stated she reported the incident to the Ombudsman (an advocate for residents of nursing homes, board, and care homes, and assisted living facilities) the same day on 2/9/2021. A review of the facility report indicated the facility completed and faxed Resident 1’s allegations to the Long-Term Care Ombudsman on 3/4/2021. A review of an email from the facility indicated the alleged abuse was reported to the Department of Public Health on 3/8/2021 (four days later). A review the staffing Projection Sheets indicated the RN Supervisor worked Station 2 on 3/5/2021 and 3/8/2021 and worked Station 1 on 3/9/2021. During an interview with the Director of Staff Development (DSD) on 3/17/2021 at 2:51 p.m., the DSD stated the Ombudsman visited Resident 1, and notified the facility of abuse allegation complaint on 3/4/2021. During an interview on 3/17/2021 at 2:59 p.m., the Director of Nursing (DON) stated she was made aware of the alleged abuse on 3/4/2021 when the Ombudsman came to visit the facility. The DON stated the Ombudsman asked them for their report and supporting documents on the abuse allegation and would call back with the evaluation. The DON stated the abuse allegation was reported to the Department of Public Health on 3/8/2021. During an interview, on 3/17/2021 at 3:35 p.m., regarding Resident 1’s allegations, the DON stated, "Yes, we should have reported the abuse allegation to the Department right away instead of waiting for the evaluation report." During an interview on 3/25/2021 at 9:05 a.m., the Ombudsman stated she visited the facility on 3/4/2021, and spoke with Resident 1. The Ombudsman stated, "The DON was informed, and I requested for the report. I did not tell them to wait or to not report it to the Department, it should always be reported. That's part of the process." During an interview on 4/20/2021 at 3:50 p.m., the DON stated Resident 1's room was located on Station 2 and Resident 1 was at risk for repeated abuse if the abuse allegation was not reported timely. Regarding the RN Supervisor, the DON stated, "No she was not suspended. I wrote her up." The DON stated, "She was not transferred right away because I discussed it with the Director of Staff Development (DSD), and we were waiting on the evaluation from the Ombudsman. The DON stated the RN Supervisor was transferred to Station 1 on 3/9/2021. A review of the facility's undated policy titled, “Abuse Investigation and Reporting,” indicated an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two hours if the alleged violation involves abuse or resulted in serious bodily injury. The Abuse Investigation and Reporting Policy indicated the Administrator will suspend immediately any employee who has been accused of resident abuse pending the outcome of the investigation. The facility failed to implement its abuse policy for Resident 1. On 2/9/2021, Resident 1 alleged abuse when the Registered Nurse Supervisor covered Resident 1’s mouth with her hand. The facility failed to report to the Licensing State Agency (SA, the Department) within the 2 -hour timeframe when they learned about the allegation on 3/4/2021. The allegation was reported to the Department on 3/8/2021. As a result, Resident 1 became angry and upset. The investigation of the abuse was delayed and placed Resident 1 at risk for further abuse. The above violation had a direct or immediate relationship to the health, safety, and security of the residents.