Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the Administrator and the State Survey Agency as required by their policy. Resident 41, who has diagnoses including anxiety, cognitive decline, and Alzheimer's disease, was observed by staff to have placed a brief over Resident 16's head, punched Resident 16, and threatened to harm her with a heavy object. Resident 41 also expressed a desire to kill Resident 16 multiple times during the shift. Despite these serious allegations, there was no evidence that the staff notified the Administrator until the evening shift, and the incident was not reported to the State Survey Agency. The Director of Nursing confirmed these lapses in protocol during interviews conducted on January 16, 2025.
Plan Of Correction
NHA was notified of allegation of abuse related to Resident 41. Report to DOH will be submitted. A review of current residents was completed over the last 30 days to ensure any allegations of abuse were reported. DON and/or designee will educate staff on the components of this regulation with emphasis on timely reporting of abuse to the NHA. DON or designee will audit abuse allegations for timely reporting to NHA. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.