F0609

D

Failure to Timely Report Alleged Staff-to-Resident Abuse Incidents

Philadelphia, Pennsylvania Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that all alleged violations of abuse were reported immediately, and no later than two hours after the allegation, as required by policy and regulation. The facility’s abuse policy, last reviewed in August 2025, states that the facility prohibits mistreatment, neglect, abuse, and misappropriation/exploitation of resident property, and that the Shift Supervisor/Charge Nurse is responsible for immediate initiation of the reporting process. The policy further assigns the Administrator and DON responsibility for investigation and reporting, including timely notification to the appropriate state agency per federal and state requirements.

Resident R1 was admitted with a diagnosis of Major Depressive Disorder and had a BIMS score of 15 on the January 5, 2026 MDS, indicating cognitive intactness. On February 23, 2026, at 2:45 PM, the resident reported that a nurse aide verbally, physically, and mentally abused them. The aide, identified as Employee E4, was involved in an incident in which, after saying something in Spanish to the resident, the resident grabbed the aide’s sweater and the aide responded by placing the resident in a choke hold and putting a hand on the resident’s face. This incident was witnessed by the Assistant DON, who had to separate the aide and the resident. During the investigation of this event, it was also determined that a prior verbal abuse incident between the same aide and the resident had occurred on February 21, 2026, and that this verbal abuse was substantiated.

The DON stated that she was not made aware of the February 21 verbal abuse incident at the time it occurred and only learned of it while investigating the February 23 incident. The Nursing Home Administrator similarly reported that she did not learn of the February 21 incident until the investigation of the February 23 event. Both the DON and the Administrator confirmed that both abuse incidents were reported to the State Survey Agency on February 24, 2026, rather than immediately or within two hours of the allegations, and the facility was unable to provide a written investigation related to the February 21 abuse incident. These findings demonstrate that the facility did not follow its own abuse reporting policy and did not ensure timely reporting of alleged abuse as required by federal and state regulations.