Valley Palms Care Center

During an interview on 9/5/2025 at 9:59 a.m. with LVN 1, LVN 1 stated that on 8/22/2025, at approximately 9:40 p.m., CNA 1 informed him (LVN) 1 that Resident 1 verbalized that Resident 2 hit Resident 1's legs.

LVN 1 stated that on 8/22/2025 at approximately 9:40 p.m. -10 p.m., he (LVN) 1 entered Room A and found Resident 1 in bed complaining of pain in her (Resident 1) legs. LVN 1 stated Resident 1 informed him (LVN) 1 that while attempting to go to the bathroom, Resident 2 stopped near Resident 1's bed and started hitting Resident1's legs. LVN 1 stated he (LVN 1) informed RN 1 about the alleged incident between Resident 1 and Resident 2.

During a concurrent interview and record review on 9/5/2025 at 11:10 a.m., with Registered Nurse (RN) 2, Resident 1's SBAR Forms, dated 8/22/2025 to 9/5/2025 were reviewed.

The SBAR forms indicated there was no documentation of Resident 1's assessment and physician notification on 8/22/2025 when Resident 1 reported that Resident 2 hit her (Resident 1) legs. RN 2 stated there was no documentation on Resident 1's SBAR forms that indicated Resident 1's body was assessed, and physician was notified on 8/22/2025 when Resident 1 reported an allegation of abuse by Resident 2. RN 2 stated that when an allegation of physical abuse is made by a resident, residents need to be assessed, including completing body assessment. RN 2 stated the failure to notify the physician and perform a complete body assessment could have resulted in Resident 1 experiencing injuries such as skin problems, fracture, and infection. RN 2 stated Resident 1 was at risk of physical and psychological (related to mental and emotional state of a person) harm.

During an interview on 9/5/2025 at 11:46 a.m. with the Director of Nursing (DON), the DON stated that on 8/22/2025, at approximately 10 p.m., Resident 1 told RN 1 that Resident 2 hit Resident 1's legs.

The DON stated an allegation of physical abuse was considered a change in resident's condition which required physician notification and monitoring of the resident.

The DON stated SBAR form should have been completed to identify injuries and provide necessary treatment.

The DON stated facility staff did not follow facility policy and protocol and failed to assess Resident 1 and notify Resident 1's physician when on 8/22/2205 Resident 1 reported that Resident 2 hit her (Resident 1) legs.

The DON stated the failure to follow the facility's protocol placed Resident 1 at risk of experiencing untreated physical injury and distress.During a review of the facility-provided policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 1/28,2025, the P&P indicated, If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to the state law.

The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: .f.

The resident's attending physician. ‘Immediately' is defined as: within two hours of an allegation involving abuse or result in serious bodily injury.During a review of the facility-provided P&P titled, Change in a Resident's Condition or Status, last reviewed on 1/28,2025, the P&P indicated, Our facility promptly notified the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1.

The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; .

Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.

Except in medical emergencies, notifications will be made withing twenty-four (24) hours of change occurring in the resident's medical/mental condition or status.

The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

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