Failure to Report and Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy when staff did not report an allegation of verbal abuse by a CNA towards a resident. A resident reported that a CNA yelled at them for requesting their hair to be washed twice, which led the resident to cry. The resident informed the Social Worker about the incident, but no further investigation was conducted, and the incident was not reported as required by the facility's policy. The resident was cognitively intact and dependent on assistance with ADLs, with medical conditions including left-sided weakness and paralysis due to a cerebrovascular accident, hypertension, and multiple sclerosis. Another resident, who was also cognitively intact and required supervision with ADLs, expressed feeling belittled by staff across the facility. This concern was documented in the Private Resident Council minutes, but no response was recorded, and the issue was not reported as verbal abuse. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident was not reported, indicating a failure to adhere to the facility's policy on abuse reporting. Interviews with facility staff, including the Social Worker, DON, ADON, and Administrator, revealed gaps in communication and reporting processes. The Social Worker did not collect statements from other residents involved, and the DON was not informed of the concerns raised in the Resident Council minutes. The facility's policy mandates immediate reporting of suspected abuse, but this was not followed, resulting in a deficiency in the facility's handling of abuse allegations.
Plan Of Correction
1. Corrective Action: CNA 1 and 2 were immediately educated on NJ Exec Order 26.4[R] during patient care and abuse and neglect. CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 NJ Exec Order 26.4[R] with the reassignment of staff. Resident number 6 was interviewed regarding being belittled and he states he really did not want to talk about it but that it is when they dont let me do what I want to do outside. 2. All residents in the facility have the potential to be affected by this deficient practice. 3. Department heads were in-serviced on the difference between grievances and reportable events by the Director of Nursing. Staff will be re-inserviced on the Abuse and Neglect policy. Staff will be re-inserviced on the grievance policy. 4. The administrator or designee will audit all grievances to ensure they are handled/reported accordingly. The administrator or designee will audit all partner rounds to ensure all are handled/reported accordingly. The administrator or designee will audit all resident council meeting minutes to ensure all are handled/reported accordingly. The audits will be completed and turned into the DON weekly for tracking and trending. Outcomes will be reviewed at the monthly Quality Assurance Process Improvement Committee Meeting for three months or until the committee agrees the problem is corrected.