Failure to Investigate Verbal Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents. 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. The resident also reported that another CNA yelled at them, expressing concern about getting people in trouble. Despite the resident's report to the Social Worker, the investigation was incomplete as no additional statements were collected from other residents on the CNAs' assignments. Resident #6, who declined to speak with the surveyor, had previously expressed feeling belittled by staff across the facility during a Private Resident Council meeting. The minutes from this meeting indicated that residents had concerns about staff attitudes, but no response was documented. The Recreation Director acknowledged that belittling a resident is considered verbal abuse, yet the incident was not reported or addressed. Interviews with facility staff, including the Social Worker, DON, and ADON, revealed gaps in the investigation process and communication. The Social Worker did not collect statements from other residents, and the DON was unaware of the concerns raised in the Resident Council minutes. The facility's policy on abuse prohibition requires immediate reporting and investigation of abuse allegations, but these procedures were not followed, leading to the deficiency.
Plan Of Correction
1. Corrective Action: CNA 1 and 2 were immediately educated on NJ NJ Ex Order 26.4(b) (1) during patient care and NJ Ex Order 26.4(b)(1). CNAs for resident number 3 were reassigned as requested by the resident. Resident number 3 NJ Exec Order 26.461 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 NJ Ex Order 26.4(b)(1) and states really NJ Ex Order 26.4(b)(1) but that it is when they NJ Ex Order 26.4(b)(1). 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.