Failure to Report Abuse to Law Enforcement
Penalty
Summary
The facility failed to report incidents of staff-to-resident abuse to local law enforcement, as required by regulations. This deficiency was identified during a survey where it was found that multiple staff members, including Certified Nursing Assistants and Resident Assistants, used excessive force while providing care to a resident. The incidents were captured on video footage provided by the resident's family, which showed staff members handling the resident roughly and inappropriately. Despite the evidence of abuse, the facility did not report these incidents to local law enforcement, as they believed it was the family's responsibility to do so. The resident involved in the incidents had a history of severe cognitive impairment and was dependent on staff for all activities of daily living due to conditions such as a Cerebral Vascular Accident and Hemiplegia. The resident was assessed as a high-risk victim of abuse, with a care plan in place to protect them from such incidents. However, the care plan's goal of ensuring the resident's protection was not met, as evidenced by the abusive actions captured on video. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a misunderstanding of the facility's obligations under the Elder Justice Act. The Director of Nursing acknowledged the abuse after reviewing the video footage and suspended the involved staff members but did not contact law enforcement, leaving the decision to the family. The facility only reported the incident to the Department of Health, failing to fulfill the requirement to notify local law enforcement, which constitutes a deficiency in their abuse reporting protocol.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The facility policy for Abuse reviewed/revised date was added along with the facility official letterhead. The Administrator reported the abuse on Resident #1 to the local police on 11/26/24 during the abbreviated survey. The facility Director of Nursing and Administrator have been re-educated during the abbreviated survey as well as by Regional Administrator on reporting regulations of the Elder Justice Act that requires reports to be made to at least one local law enforcement agency of jurisdiction. The facility Administrator and Director of Nursing will be re-educated by the Regional Administrator on the reporting requirements quarterly. All facility staff will be educated on the Abuse Policy and Procedure by the Director of Nursing or Designee. The facility policy will change this education from upon hire and annually, to upon hire and quarterly going forward. The Administrator will report education compliance to QAPI for 6 months. The Director of Nursing or Designee will audit staff Abuse education, which includes reporting requirements, compliance weekly for 3 months then monthly thereafter. Any findings of noncompliance will be reported to QAPI quarterly. Responsibility: Director of Nursing, Administrator or Designee