Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an allegation of neglect for a resident. The resident, who had a history of dementia, muscle weakness, and repeated falls, was admitted to the facility and had a care plan indicating potential for skin integrity impairment. An incident occurred where the resident's daughter reported a skin tear near the resident's right elbow to a Nurse Aide (NA), who then applied a bandage without cleansing the wound and failed to inform the nurse. This resulted in the wound not being properly treated, as it was not approximated and had moderate bleeding. The Director of Nursing (DON) was aware of the situation but did not investigate or report it as neglect. The facility's policy on abuse requires that reports of neglect be promptly and thoroughly investigated and reported per Federal and State Law. However, in this case, the facility did not follow its policy, as the incident was not investigated or reported as required. The failure to implement these policies and procedures led to the deficiency identified by the surveyors.
Plan Of Correction
1. The incident that occurred with resident #R1 was reported to the Pennsylvania Department of Health and Adult Protective Services on 12/26/2024. A thorough review of all incidents current resident records will be conducted to identify any instances where the failure to report incidents, changes in condition, or abuse/neglect was noted. This review will cover the past 30 days from the date of the citation. 2. All relevant incidents, including changes in a resident's condition, suspected abuse, neglect, or other critical information that should have been reported, will be documented and immediately reported to the appropriate agencies as per state regulations. Staff will also ensure that these incidents are fully documented in resident records. The Senior Director of Clinical Services will re-educate the director of nursing and executive director of health services on the abuse and neglect policy to ensure that instances that may be considered abuse or neglect are reported timely as appropriate to the designated agencies. The Director of Nursing and Executive Director of Health Services or their designees will re-educate team members by the compliance date on the need to report all incidents where there is a need for nursing intervention to ensure if there is any evidence of potential abuse or neglect that it gets reported immediately to nursing supervisors and addressed immediately with the abuse reporting compliance team. The Director of Nursing/designee will audit incidents and accidents weekly for six weeks to ensure a thorough investigation has occurred and if necessary appropriate reporting has been submitted through PA Department of Health's Event Reporting System. The results of these audits will be shared with the Quality Assurance Performance Improvement Committee for review of trends that may require further action.