Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of allegations of abuse and neglect involving multiple residents. Specifically, incidents involving inappropriate sexual behavior by a resident with cognitive impairment were not adequately addressed. For instance, a cognitively impaired resident was touched inappropriately by another resident, but there was no timely assessment or notification to the family and medical provider. Additionally, interventions to protect the affected resident and other vulnerable residents were not implemented promptly. Another incident involved a resident with dementia who exhibited sexually inappropriate behaviors towards other residents on multiple occasions. Despite these repeated incidents, the facility did not conduct thorough investigations to identify the residents involved or assess the impact on them. There was a lack of documentation regarding the assessment of the affected residents and notification of their families and medical providers. Furthermore, the facility's incident reporting process was inadequate, as several incidents were not documented or investigated in a timely manner. Staff interviews revealed inconsistencies in the completion of incident reports and assessments, with some staff unable to recall details of the incidents or the residents involved. The facility's failure to adhere to its abuse prevention and reporting policy resulted in a lack of protection and support for the residents involved.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 F 610 483.12 Abuse and Neglect 1. Immediate Corrective Action: - Resident #4 does not recall the incident from 5/20/23 and continues to participate in her plan of care. - Resident #2 was discharged from Valley View Manor on 3/26/24. - Resident #5 had an RN assessment and was interviewed by the Director of Nursing on 12/20/24 and stated she is not terrified and is no longer uncomfortable around resident #1. - Resident #1 had his care plans reviewed on 12/20/24. No revisions are currently needed. - LPN #4, LPN #8, LPN #1 and RN #7 will be educated on the Abuse prevention and Reporting Policy and procedures by 12/27/24. - LPN #16, LPN #14, LPN #9, RN #19, LPN #15 and RN #20 are no longer employed at Valley View Manor. 2. Identification of Others: - The facility respectfully submits that all current and future residents have the potential to be affected by this deficient practice. - The Director of Nursing conducted interviews with all cognitive residents residing on resident #1 unit on 12/20/24 regarding the care and services they receive. There were no other allegations of abuse, neglect, misappropriation and exploitation made at the time of these interviews. During the interviews all residents denied being fearful or expressed psychological effects as a result of resident #1 or any other resident. 3. Measures/ Systemic Changes: - The facility will conduct the following to prevent this practice from occurring in future: - Abuse Prevention and Reporting Policy was reviewed with revisions to include: - Investigation: - victim and aggressor assessment, - obtaining statements from involved residents and witnessing residents, - Resident statements will be attempted despite cognitive status - All involved and witnessing residents will be monitored to determine psychological effects or change in behavior by social services or designee. - The following information must be available for the investigators upon request: - All statements obtained - The Administrator/Director of Nursing will be notified immediately of any allegation of Abuse. An investigation will be initiated, the Victim and Aggressor will have a timely assessment completed, Accident and Incident initiated with staff statements, resident(s) statements, and any other potential witnesses. Emergency contact and medical provider notified timely and immediate care plan interventions initiated. Involved and witnessing residents will be interviewed and followed up for any potential psychological effects or change in behavior. Pending the outcome of the investigation, timely notification to state and local agencies will be completed. All staff that provide care to the involved residents will be notified of the interventions. - Education and in-servicing will be provided to all employees on the Abuse Prevention and Reporting Policy and revisions with emphasis on the importance of reporting immediately to the Administration team to ensure a full and timely investigation is completed and the procedures found in the policy are followed. Education and in-servicing will be completed upon new hire, annually and as needed by the Director of Nursing/Designee. 4. Quality Assurance Monitoring: - The Administrator/Designee will investigate all reports of Abuse and Neglect to ensure a full investigation is completed and the Abuse Prevention and Reporting policy and procedures are followed. All accident and incident reports will be reviewed in the morning report to ensure that Accident and Incident reports are completed accurately, timely, and thorough. Accident and Incident reports will be audited weekly to ensure that all reports are completed timely, nursing assessments, witness statements obtained and notifications of family and medical have been completed. Any issues identified from these audits will be corrected immediately, and the information obtained from the audits will be reviewed at the Quality Assurance meeting. 5. Responsible Party and Expected Date of Completion: - The Administrator/ Designee is responsible for correcting this deficient practice and completion date (MONTH) 26, 2025.