Failure to Prevent and Report Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent physical and verbal abuse towards a resident by a staff member, specifically the Director of Nursing (DON), who was observed hitting a resident with a broom. This incident was recorded by a Licensed Practical Nurse (LPN) and later circulated on social media, prompting a police investigation. The abuse was witnessed by several staff members, including another LPN, a Certified Nursing Assistant (CNA), and a Housekeeper, none of whom intervened or reported the incident. The DON was heard making a threatening statement towards the resident during the incident. The incident occurred when the DON was called to the unit due to the resident's aggressive behavior. The resident, who had a history of major depressive disorder, dementia, and epilepsy, was reportedly agitated and threw a chair at the DON. The DON then used a broom to hit the resident, who was allegedly holding a blue disposable razor. The facility's reportable event documentation did not include a thorough investigation or proper notification to the Department of Health, and the DON remained employed for an extended period after the incident. The facility's policy on abuse was not followed, as the incident was not reported immediately, and the staff involved were not removed from resident care promptly. The DON had received training on abuse prior to the incident, yet failed to adhere to the facility's protocols. The lack of intervention and reporting by the staff present during the incident further contributed to the deficiency, as they did not take appropriate action to protect the resident or notify the authorities.
Plan Of Correction
Immediate Action On NEX OTGOT 20.4161 US. FOLA (was suspended pending investigation. (Terminated) NJ Ex Order 26. 481. Administrator/ADON/HR contacted Board of Nursing on 12/30/2024 to report involvement in incident, and to report the two nurses who observed, recorded video and did not intercede to help, but sent the video to a friend to post. Those nurses no longer work at facility. C.N.A. #1 and C.N.A. #3 were reported to Department of Health for not interceding to help and not reporting. 12/24/24 Education was given to staff C.N.A. #1, and C.N.A. #3, and on how to follow company policy on abuse and report immediately to the abuse coordinator, intervene and call the police. 12/24/24 Morning/clinical meeting audit process started to assure allegations of abuse and neglect and grievances are addressed and investigated within policy. Audits will be completed 3x weekly for the next 4 weeks and monthly for the next 6 months. Other residents having potential to be affected by the same deficient practice All residents have the potential to be affected by this deficient practice. What measures will be put into place or systemic changes made to ensure that the deficient practice will not return. On 12/23/24, (completed 12/25/24) the Assistant Director of Nursing/or designee immediately educated all staff on abuse, neglect and exploitation and deescalating resident behavior, and the importance of reporting all incidents to the abuse coordinator timely, calling police, and intervening. The Interim DON/designee will conduct this education monthly for the next six months. Administrator/DON/ADON/designee will audit education each month to assure all employees have had education. Audits will be conducted 3x's weekly for four weeks and then monthly for the next six months. The Administrator/Interim DON/designee will audit compliance with the education on abuse and conduct 5 random staff assessment and test to assure staff have a true understanding of the facilities abuse policy. Audits will be completed 3x's weekly for four weeks and then monthly for the next four months. The education on the facilities abuse policy and the importance of reporting all incidents to the abuse coordinator immediately, interceding in the situation and calling the police, will become part of our orientation education as well as our annual education. 12/30/2024 Ad Hoc Resident council meeting was held to educate residents on abuse and to ask that if they see something to please say something. Social services/activity director educated them on the signs hanging on units for calling the abuse coordinator, and for calling the ombudsman office. The resident rights were read. How the facility plan to monitor its performance to make sure that solutions are sustained. The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on February 21, 2025.
Removal Plan
- Education to all staff on abuse, neglect, and exploitation.
- Education on intervening and calling the police if abuse was witnessed.
- Education on what to do when abuse was reported and the process for reporting abuse.
- A third-party consultant company completed an audit that reviewed all incident and accident reports to ensure that each incident included a thorough investigation and appropriate follow-up.
- The third-party consultant company provided the facility with recommendations based on the audits.
- The staff within the video that witnessed the incident between the DON and Resident #1 were no longer working at the facility.
- The Human Resources Director (HRD) received education from the ADON on the proper reporting process when an abuse allegation was reported to her.
- CNA #1 and CNA #3 who witnessed the incident but were not in the video, continue to work at the facility and education was provided to both staff on intervening and calling the police if abuse was witnessed.