Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin, as evidenced by two specific incidents involving residents. In the first incident, a resident with Alzheimer's disease and severe cognitive impairment was found with a hematoma on the forehead, which was not witnessed by any staff. Despite the resident's inability to communicate how the injury occurred, the facility did not conduct a comprehensive investigation to determine the cause of the injury. Interviews with staff revealed inconsistencies in their accounts, and there was no documented evidence of a thorough investigation or rationale for not reporting the incident as required by facility policy. In the second incident, a resident-to-resident altercation occurred involving three residents, resulting in two residents being pushed to the floor and sustaining injuries. The facility's investigation was incomplete, as it did not include an incident report for the resident identified as the aggressor. Interviews with staff indicated that the incident was not reported to the Department of Health, and the facility did not consider the incident as abuse due to the cognitive impairments of the residents involved. The Director of Nursing and Assistant Director of Nursing failed to ensure that all necessary documentation and reporting were completed. Overall, the facility did not adhere to its policy on abuse prevention and reporting, which requires immediate reporting and thorough investigation of all alleged violations. The lack of a comprehensive investigation and failure to report these incidents demonstrate a deficiency in the facility's handling of potential abuse and injury cases, compromising the safety and well-being of the residents involved.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F610 Corrective Actions for Residents Identified: No further occurrences related to abuse, including injury of unknown origin, resident-to-resident altercation, neglect, and mistreatment, were identified by the ADNS/Risk Manager. All accidents/incidents will be reviewed and reported immediately if they meet the reporting criteria but not later than 2 hours. Abuse care plans are in place for all 3 residents, #251, #214, #268, and #589 (no longer in the facility). Resident #251 is placed in the hallway or the dining room with activities for close observation. Resident #214 is placed in the hallway or in the dining room with activities for close observation. Resident #268 is placed at the nursing station with activities for close observation. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The ADNS and DNS completed an audit tool to review accidents/incidents investigated in the past three months to determine whether an occurrence is abuse, neglect, injury of unknown origin, or mistreatment. This alleged deficient practice has not identified similar findings or adverse effects. Element 3 Systemic Changes: The Administrator, Director of Nursing, Assistant Director of Nursing, and Medical Director will continue to review and revise, as indicated, the policies and procedures related to Abuse Prevention, including timely reporting of all allegations and or observations of abuse to the Administrator and other officials as outlined in the regulations and State Law. The ADNS will in-service staff in all departments on abuse prevention, focusing on initiating an investigation of abuse allegations. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: ADNS (Risk Manager) or designees will review the 24-hour report and all accidents or incidents to ensure there are no allegations that need to be investigated or any occurrences that require investigation for the next 4 weeks. The DNS will audit all AI weekly for four weeks to ensure that outstanding issues and incidents requiring investigation are compliant and have no outstanding issues. DNS will report to the Administrator. DNS will report to QAPI for one quarter. QAPI Committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Responsible Person: Director of Nursing, Assistant Director of Nursing, and Administrator.