Failure to Report Allegations of Verbal Abuse
Penalty
Summary
The facility staff failed to report an allegation of verbal abuse involving two residents to the administration and the New Jersey Department of Health as required by their Abuse Prohibition policy. Resident #3 reported an incident where a CNA yelled at them for requesting their hair to be washed twice, which led to the resident crying. This incident was reported to the Social Worker, but no further investigation was conducted, and the incident was not reported to the appropriate authorities. Additionally, Resident #6 expressed feeling belittled by staff across the facility, but this concern was not documented or addressed in the Resident Council minutes. Resident #3, who was admitted with conditions such as left-sided weakness and paralysis due to a cerebrovascular accident, hypertension, and multiple sclerosis, was cognitively intact and dependent on assistance with activities of daily living. The Social Worker collected a statement from Resident #3 but did not interview other residents on the staff member's assignment. The Director of Nursing was not informed of the concerns raised in the Resident Council minutes, and no investigation was initiated for the verbal abuse allegations. The facility's policy mandates immediate reporting of suspected abuse, but this was not adhered to in these cases. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident involving Resident #6 was not reported. The Assistant Director of Nursing and the Administrator were also unaware of the concerns raised, indicating a breakdown in communication and reporting procedures within the facility.
Plan Of Correction
Reporting of Alleged Violations 1. Corrective Action CNA 1 and 2 were immediately educated on being considerate during patient care and abuse and neglect. CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 is very happy with the reassignment of staff. Partner Rounds were initiated where every patient is assigned to a department head to see several times weekly to handle/report any concerns. Resident number 6 was interviewed regarding being [R] and states really NJ Exec Order 26.4b1 but that it is NJ Exec Order 26.4b1[R]. 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. 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.