Failure to Follow Abuse Policy and Verify Licensure
Penalty
Summary
The facility failed to adhere to its abuse policy for one of the residents reviewed, identified as Resident 28. The resident, who was cognitively intact and dependent on staff for all daily care needs, was subjected to verbal abuse by Nurse Aide 3. On October 31, 2024, Nurse Aide 3 was overheard telling Resident 28 to "shut up," which was confirmed by the facility's investigation. This incident led to the termination of Nurse Aide 3, as it was determined that the aide did not follow the facility's abuse policy. Additionally, the facility did not complete a professional licensure verification for one of the employees reviewed, Registered Nurse 2, with the Pennsylvania State Board of Nursing prior to her hire. Registered Nurse 2 was hired on September 10, 2024, but as of January 13, 2025, four months after her hire date, there was no documented evidence of licensure verification. This was confirmed by the Director of Human Resources, indicating a failure to comply with the facility's policy on verifying professional licensure before employment.
Plan Of Correction
1. Resident 28 currently resides in the facility and is safe for overall well-being. Nurse Aide 3 has been terminated on 11/4/2024. Registered Nurse 2's professional licensure verification with the Pennsylvania State Board of Nursing had been completed on 1/13/2025. 2. On 2/3/2025, the Nursing Home Administrator and Director of Nursing began re-education for all staff on abuse policy including procedure for reporting abuse, neglect, and resident rights. On 2/6/2025, in-service education began for all staff by the Social Services Director on abuse policy including procedure for reporting abuse, neglect, and resident rights. 3. Measures/systemic changes made to ensure that the deficient practice will not recur. Quarterly training will be conducted by the Social Worker for staff on abuse, neglect, and resident rights. Training for all staff on abuse, neglect, and resident rights to include reporting of abuse and neglect for newly hired employees. 4. The Social Services Director will complete resident interviews for abuse monitoring with interviewable residents weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. The Social Services Director will complete resident observation for indicators of abuse for residents considered non-interviewable weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. 5. Resident interviews for abuse monitoring will be reviewed by the Nursing Home Administrator weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. The facility plans to monitor performance to make sure solutions are sustained. 6. The Nursing Home Administrator will report all findings of resident interviews for abuse monitoring to the Quality Assurance and Performance Committee monthly for a minimum of 3 months.