Failure to Report and Intervene in Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of witnessed staff-to-resident physical and verbal abuse to the Department of Health and the local Police Department. The incident involved a staff member, identified as the Director of Nursing (DON), hitting a resident with a broom. The event was captured on video and later found on a social media website. Several staff members were present during the incident but did not intervene. The Assistant Director of Nursing (ADON) confirmed the identities of the staff involved and the resident, who was identified as Resident #1. Resident #1, who was admitted with diagnoses including Major Depressive Disorder, Dementia, and Epilepsy, was involved in the incident. The resident's cognitive status was severely impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident's care plan noted a history of verbal and physical aggression, with interventions to redirect and provide diversional activities. However, there was no documentation in the resident's progress notes regarding the incident or any notification to the police or hospital transfer on the date of the incident. The facility's policies on abuse and incident reporting were not followed. The DON, who was involved in the incident, was suspended pending an investigation. The ADON and other staff members were unaware of the full details of the incident until the video surfaced. The facility's policy required immediate reporting and intervention in cases of abuse, which did not occur in this situation. The local police were not notified at the time of the incident, and the facility failed to provide evidence of reporting the event to the Department of Health.
Plan Of Correction
Immediate Action On NJ Ex Order 26. 481 US. FOLA (b was suspended pending investigation. (Terminated NJ Ex Order 26. 481. On 12/21/24 a third-party consulting company was contracted to conduct an independent investigation of the abuse allegation which comprised of review of documentation, care plans, interviews of staff, observation of resident, review of reportable information from Wax Order 26. 4B1 12/23/2024 (completed 12/25/24). Education began on abuse and the importance to report any allegation of abuse immediately. 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 the U.S. FOIA (b) (6) began education on abuse and the importance to report any allegation of abuse immediately to abuse coordinator, investigation starts immediately and to follow the steps of our accident incident policy to call police and to report to the Department of Health and Ombudsman. Education on our Accident Incident policy will be given monthly for six months. The Abuse and Accident Incident policy education will become part of our orientation education as well as our annual education. The Administrator/Interim DON/designee will audit compliance with the education on Abuse and Accident Incident policy and conduct 5 random staff assessment and test to assure staff have a true understanding of the facility Accident Incident 3 times a week for the first four weeks and then monthly for four months. Administrator/DON/ADON/designee will audit abuse reportable events to observe and to assure the steps in the facility policy are followed such as timeliness of reporting incident, completeness of investigation and that all statements are collected and are in their original signed form, police contacted, and reported to DOH and the Ombudsman office. Audits will be conducted three times a week for one month and then monthly for four months. How the facility plans 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.