Failure to Timely Report Abuse Investigation
Summary
The facility failed to report the complete investigation of an allegation of abuse within the required time frames. A resident, who had been admitted with diagnoses including rectal cancer, pain, cellulitis, and anxiety, alleged that the Nursing Home Administrator physically abused him by pushing him in the chest. The incident was reported to the State Event Reporting System the following day, and the investigation was deemed unsubstantiated. However, the required PB-22 form, which documents allegations of abuse with an identified alleged perpetrator, was not completed and submitted within the mandated five-day period. This delay was confirmed by the Assistant Nursing Home Administrator during an interview.
Plan Of Correction
The PB-22 form has been completed and submitted. Employee E2 was re-educated on the importance of following proper protocol and timeframes for completing and submitting the PB-22 form within five days of an abuse allegation. NHA/designee will complete an audit reviewing the past 30 days to ensure all PB-22 forms have been completed. Then weekly x4 audits to review the timely submission of PB-22 forms for any future abuse allegations. Audit results will be reviewed by the Director of Nursing or designated supervisor. Findings will be reported to QAPI monthly x3.
Penalty
The facility did not submit required PB-22 forms for six reported events involving allegations of abuse, neglect, or misappropriation of property by staff, including nurse aides, a van driver, the DON, and a nurse. Despite multiple reminders and confirmations from leadership, the forms remained incomplete for all events.
A resident with dementia and frequent falls experienced two significant falls requiring hospital transfers. The facility failed to report these incidents to the Department of Health within the required 24-hour timeframe. The DON confirmed the first fall should have been reported, while the second was not reported due to miscommunication about the resident's condition.
Failure to Submit Required PB-22 Forms for Abuse and Neglect Allegations
Penalty
Summary
The facility failed to submit completed PB-22 forms to the Department as required for six separate reported events involving allegations of abuse, neglect, or misappropriation of property. Each event involved a resident making an allegation against staff, including nurse aides, a van driver, the Director of Nursing, and a licensed nurse. The allegations included failure to provide proper care after a bowel movement, not providing care overnight resulting in a resident being found wet with urine, verbal altercations with staff, failure to provide proper care during a bath, not providing drinking water, and inappropriate response to requests for pain medication. Despite multiple notifications and reminders sent electronically to the Nursing Home Administrator and the Director of Nursing over several months, the required PB-22 forms for these events were not completed or submitted. Interviews with facility leadership confirmed the ongoing failure to complete the forms, and documentation reviews on several occasions showed that the deficiency persisted. The lack of submission of these forms was confirmed repeatedly by both the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
Submitted all outstanding PB22's to event report portal. Re-education for NHA and DON on timely submission of PB22's. Audit weekly x4 and monthly x3 to be completed by corporate team to determine timely submission of all PB22's. Results of audits will be submitted to monthly QAPI meeting. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey.
Failure to Report Resident Falls Within Required Timeframe
Penalty
Summary
The facility failed to report serious incidents involving a resident to the Department of Health within the required 24-hour timeframe. Resident 48, who had diagnoses including dementia, anxiety disorder, and frequent falls, experienced two significant falls that required hospital transfers. The first incident occurred on February 16, 2025, when the resident fell, resulting in a hematoma on the forehead and abrasions on the arm and finger, leading to a hospital transfer for further evaluation and treatment. The second incident took place on February 23, 2025, when the resident fell again, sustaining a bump on the forehead and a scratch on the arm, and was transferred to the hospital due to a closed head injury and ambulatory dysfunction. The facility did not report either of these incidents to the Pennsylvania Department of Health's event reporting system. During an interview, the Director of Nursing confirmed that the first fall should have been reported but was not. The second fall was not reported because the transfer was attributed to the resident's ambulatory dysfunction rather than the fall itself. The DON was not informed about the hematoma at the time of the incident, which contributed to the failure to report the incident as required.
Plan Of Correction
1. R48 was reported as required on 4/8/25. 2. No other ERS reporting was identified as not submitted. Education was provided by the Regional Clinical nurse or designee to the new DON on ERS reporting requirements. 3. Incident reports will be audited by the DON or designees to ensure that any incidents requiring reporting is completed timely weekly x 4. 4. Audits will be taken to QAPI for review and further interventions if warranted.
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