Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who no longer resides at the facility. The resident, who had a history of anxiety disorder, major depressive disorder, muscle weakness, difficulty in walking, and the presence of an artificial eye, was found on the floor beside their bed with their head under their wheelchair. The resident required substantial maximal assistance with activities of daily living and transfers and had some cognitive impairment. After a fall, the resident was sent to the hospital, where they reported being pushed, prompting an investigation by hospital social workers. However, the facility did not complete a thorough investigation as required by their policy. The facility's policy mandates that all reports of abuse, neglect, exploitation, or misappropriation are thoroughly investigated and documented. The investigation should include interviews with the person reporting the incident, any witnesses, the resident or their representative, and staff members who had contact with the resident. Despite this, the facility's investigation was incomplete, as acknowledged by the Administrator, who only became aware of the allegation after gathering documentation. The Director of Social Services, who was not employed at the time of the incident, stated that she would typically collect statements from the resident making the allegation but did not speak with other residents. The facility's failure to adhere to its policy resulted in an incomplete investigation of the abuse allegation.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 NJ Ex Order 26.4(b)(1) at the facility. The Administrator immediately conducted an audit of all reportable events in 2024 involving allegations of NEXTER to ensure the allegation was thoroughly investigated. There were no untoward findings. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents who report an allegation of abuse have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/26/2024 the facility Administrator (LNHA) conducted in-service education with the U.S. FOIA (b) (6), the U.S. FOIA (b) (6), and Unit Managers (UM) on the policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating. Education included but was not limited to all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies & thoroughly investigated by facility management. On 12/26/2024 the FE/ADON conducted in-service education to line staff on the procedure for reporting allegations of abuse. On 12/26/2024 the Director Of Social Services conducted an audit of all grievances from 2024 to ensure all grievances were investigated and there were no allegations of abuse or mistreatment. There were no untoward findings. The LNHA is the designated individual at the Facility to investigate all allegations of Abuse, Neglect, Exploitation or Misappropriation. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Director of Social Services or designee will conduct audits of all reported resident concerns or grievances to ensure allegations are immediately reported to the Administrator for a full and thorough investigation. Audits will be conducted daily x 5 days, then weekly x 4 weeks, then monthly x 3 months. The results of the audits will be provided monthly x 3 months, then quarterly x 3 quarters to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee for review and comment. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.