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Based on record review and interview, the facility failed to ensure that all alleged violations involving mistreatment, or abuse were reported immediately to the State Agency for 1 (# 1) of 3 sampled swing bed patients.

Findings include:

Review of swing bed patient (SBP) #1's nursing notes, dated 12/16/17, described an incident between SBP #1, a nurse, and an aide. There was a hole in a urinal the resident used, consequently soaking him and his bed. The note described the hole in the urinal was about the size of a pen. The SBP denied putting the hole in the urinal. The nurse and the aide believed he had put the hole there.

In an interview on 2/13/18 at 2:30 p.m., staff member B stated the SBP will argue with the nurses about things. When the nurses say something otherwise, he states, "So you are calling me a liar?"

In an interview on 2/13/18 at 2:30 p.m., staff member A stated that the facility has had the ombudsman involved with SBP #1 for a long time. They have also set up appointments for him with a counselor to help the SBP through bouts of depression and frustration.

In an interview on 2/13/18 at 1:10 p.m., non-facility member NF3 stated, the swing bed patient felt like the nurse and aide were calling him a liar. He also stated he is treated like a child, and if he complained, he would be treated worse. Non-facility member NF3 stated Adult Protective Services sent a letter to the facility of an intent to investigate an allegation of abuse on 12/27/17.

After receiving this letter, the facility still failed to report this allegation of abuse to the State Agency.

In an interview on 2/13/18 at 2:30 p.m., staff member A stated the facility did not identify it as abuse and conduct an investivation to report to the State Agency, as they were trying to get the SBP help through the ombudsman program and counseling. Staff member A stated they were not sure if a critical access hospital was held to the same reporting requirements as a long term care facility.