Failure to Investigate Possible Abuse/Neglect Incident
Penalty
Summary
The facility failed to investigate an incident involving possible abuse or neglect of a resident. The incident involved a resident who fell from a Broda chair and sustained a large hematoma on the forehead, along with other symptoms such as dizziness and an upset stomach. The resident was sent to an acute care facility to rule out a head bleed, and upon return, was found to have bruising and fecal smearing. The facility's policy requires immediate reporting and investigation of suspected abuse or neglect, but this was not followed in this case. The resident's care plan included a specific toileting program, which was not adhered to, leading to the fall. The resident had been observed earlier attempting to move forward in the Broda chair and was repositioned by staff. Despite these observations and the fall, the facility did not conduct an investigation into potential abuse or neglect, as confirmed by an interview with a licensed employee. The failure to follow the care plan and the lack of investigation into the incident constitute the deficiency.
Plan Of Correction
The Facility will conduct a review of all current residents in similar situations for which an Electronic Event Report was submitted to the Pennsylvania Department of Health during the period January 9, 2024 to January 9, 2025. The Neglect Screening Tool will be utilized to conduct this review by the Interdisciplinary Team to ensure there were no other instances that required further investigation to determine neglect. Review will be completed no later than 2/28/25. Findings of this audit will be shared with the Facility Quality Assurance Committee at the next quarterly meeting. All staff will be re-educated on Facility Policy and Procedure titled Resident Abuse/Neglect/Misappropriation of Property Prevention (12/23) no later than 2/21/25. The training referenced above will also include discussion of the procedures to follow where, in different situations than this, "neglect" is found, and the subsequent investigations and reporting that must accompany such a finding. A follow-up review of incident and resident 52's medical record was conducted on January 20 -23, 2025 by Administrator, Director of Nursing, Medical Director and members of the Interdisciplinary Team. A Preventative Abuse Incident Monitor will be conducted by NHA or designee to include: Missing Property, Skin Incidents of Unknown Origin and Events Reported to Department of Health involving Abuse, Neglect, Misappropriation. This monitor will include any similar situations involving Event Reports submitted reported to the Pennsylvania Department of Health in which the checklist was utilized. Findings will be reported at the Quarterly QA Committee Meeting.