Failure to Investigate and Report Abuse Allegation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of witnessed staff-to-resident physical abuse. The incident involved the Director of Nursing (DON) hitting a resident with a broom, which was recorded by an LPN and later posted on social media. The video showed several staff members present during the incident who did not intervene. The DON was identified as the staff member holding the broom, and the resident involved was identified as Resident #1. The incident was not reported to the Department of Health, and the DON remained employed at the facility until her suspension months later. Resident #1, who was involved in the incident, had a history of major depressive disorder, dementia, and epilepsy. The resident's cognitive status was severely impaired, as indicated by a low score on the Brief Interview for Mental Status (BIMS). The resident's care plan noted a potential for verbal and physical aggression, with interventions to allow verbalization of frustrations and provide diversional activities. However, there was no documentation in the resident's progress notes regarding the incident, police notification, or hospital transfer. The facility's policies required immediate action and thorough investigation of abuse allegations, which were not followed in this case. The DON conducted the initial investigation but failed to report the incident to the appropriate authorities. The facility's policy also required the removal of any employee involved in abusive activity from resident care, which did not occur until the DON's suspension. The lack of intervention by other staff members present during the incident further contributed to the deficiency.
Plan Of Correction
Immediate Action On [R] was suspended pending investigation. (Terminated [R]) 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 [R]. Audit of all incident and accident reports from Waxed to present was conducted to ensure that each incident included a thorough investigation and appropriate follow up. Audit completed 12/26/2024. 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's weekly for the next 4 weeks and monthly for the next 6 months. 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 the Department of Health for not interceding to help and not reporting. 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 investigation protocols, importance of collecting all statements, utilizing the social worker to assist in obtaining the residents statements, assuring the original signed statements are turned into the abuse coordinator, Police are called and reporting all incidents to the abuse coordinator immediately and within 5 days turn in all findings of investigation to Administrator. The Interim DON/designee will conduct this education on abuse investigation protocols for the next six months. Administrator/DON/ADON/designee will audit education each month to assure all employees have had education. Audits will be completed 3x weekly for the next 4 weeks and monthly for the next 6 months. The Administrator/Interim DON/designee will audit compliance with the education on abuse investigation and conduct 5 random staff assessment and test to assure staff have a true understanding of our abuse policy. Audits will be completed 3x's weekly for four weeks and then monthly for next four months. The education on the facility protocols on abuse investigations will become part of our orientation education as well as our annual education. Administrator/Interim DON/ADON/designee will audit abuse reportable events to observe and to assure completeness of investigation and that all statements are collected and are in their original signed form, police were called, incident is reported to Department of Health and Ombudsman. Audits will be conducted three times weekly for four weeks, then monthly for the next four months. 12/30/2024 Ad Hoc QAPI meeting was held to review the results of the third-party consulting company's 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 NJ Esx Order 26. 481. In addition, audit of all incident and accident reports from [R] to present was conducted to ensure that each incident included a thorough investigation and appropriate follow up. Audit completed 12/26/2024. 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 conducting a thorough investigation related to an abuse allegation.
- A third-party consultant company completed an independent investigation of the abuse allegation which was comprised of a documentation review, review of the resident's medical records, staff interviews, resident observations, and a review of the reportable event.
- The third-party consultant company conducted an audit of all incident and accident reports to ensure that each incident included a thorough investigation.
- The Licensed Nursing Home Administrator (LNHA) implemented a daily audit to assure abuse allegations were addressed and investigated according to the facility's policy.