Resident Abuse Incident Involving Admission Clerk
Penalty
Summary
The facility failed to ensure the residents' right to be free from physical abuse by nursing home staff, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, diagnosed with Vascular Dementia, Psychotic Disorder with Delusions, and Major Depressive Disorder, approached an Admission Clerk with raised arms. In response, the Admission Clerk pushed the resident, causing them to fall backward and hit their head on a desk. This incident was captured on video surveillance, and the resident was subsequently transferred to the hospital for evaluation. The facility's policy on reporting and investigating resident abuse, neglect, and mistreatment was not adhered to in this case. The policy aims to provide a safe environment and protect residents from abuse. Despite the resident's known history of aggressive behavior, the staff involved did not follow the proper protocol for handling such situations. The Admission Clerk's reaction was deemed inappropriate, as staff are instructed to back away, call for help, and not retaliate when faced with aggressive behavior from residents. Interviews with various staff members, including Certified Nursing Assistants, a Licensed Practical Nurse, and the Registered Nurse Supervisor, revealed that the incident was not handled according to the facility's guidelines. The staff acknowledged that the Admission Clerk's actions were not acceptable and that the proper response should have been to shield from the aggressor and call for assistance. The facility's investigation concluded that the Admission Clerk violated the policy, leading to their termination.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 I. Immediate Corrections - Resident #1 was thoroughly assessed following the incident and promptly transferred to the hospital emergency room. After a complete evaluation, the resident returned to the facility with no injuries. - Admission Clerk #1 was immediately suspended pending a comprehensive investigation. Upon the conclusion of the investigation, the staff member was terminated in accordance with facility policy and standards. - The incident was reported to NYSDOH on 10/25/2024 at 15:00, complaint number NY 641. - All facility staff were educated on abuse prevention. II. Identification of Other Residents - No other residents were identified to have complaints regarding staff treatment. - Social worker followed up with the residents of the unit to provide emotional and psychosocial support. The residents stated that they were not fearful of any additional incident. - The comprehensive care plans of all residents were checked to ensure there was a plan in place to prevent abuse, and specific interventions that were resident centered. All care plans were found in compliance with the protection of our residents. A copy of resident care plan is available in the EMR. III. Systemic Changes - The facility’s policy and procedure titled Abuse Prevention was reviewed and found appropriate. - All clinical and non-clinical staff (All RNs, LPNs, C.N.A.s, Admissions Staff, Recreation Staff, Housekeeping Staff, Engineering Staff, Administrative Staff, Social Service Staff, Rehabilitation Staff, and Dietary Staff) were re-educated by the Nurse Educator/Designee on the policy/procedure. These sessions reinforced the processes and responsibilities outlined in the Abuse Prevention policy to ensure consistent implementation across all departments. The attendance sheet will be kept on file for validation. - The facility will continue to provide education upon hire, annually and as needed on the Policy and Procedure on abuse, neglect, and mistreatment. - Staff hourly observational rounds of all residents will continue. IV. QA Monitoring - An audit tool was developed to ensure that no abuse, neglect, or mistreatment occurred. - The Audit tool will concentrate on resident complaints about staff treatment. - Audits of 5 residents will be performed by Social Services weekly x 4 weeks, then monthly for 2 months. - Any negative findings have immediate corrective action taken and reported immediately to the Administrator. - Results of the audits will be reported monthly and reviewed by the QAPI committee. Continuation, modification, or discontinuation of audits will be based on QAPI committee’s recommendations. Person Responsible: Director of Social Services