Failure to Report and Investigate Resident Condition
Penalty
Summary
The facility failed to report and initiate an investigation for a specific incident involving a resident, identified as Resident #47, until prompted by a surveyor's inquiry. The deficiency was identified when the surveyor observed Resident #47 in bed and attempted to interview them, but the resident was unresponsive. Subsequent interviews with Certified Nursing Assistants (CNAs) revealed that they had noticed a condition on the resident but did not report it, assuming it was already known by the staff. Further investigation showed that the facility had not conducted a proper investigation into the incident involving Resident #47, despite having policies in place that required immediate reporting of any suspected abuse, neglect, or injuries of unknown origin. The CNAs involved had received training on these policies, but there was a lapse in communication and reporting, as they did not inform the nursing staff about the resident's condition. The Licensed Practical Nurse (LPN) and other staff members were unaware of the issue until it was brought to their attention by the surveyor. The resident's medical records and individualized plan of care indicated that they required assistance with activities of daily living and had certain medical conditions. However, there was no documentation of an assessment being completed for the resident's condition until after the surveyor's inquiry. The facility's failure to adhere to its own policies and procedures for reporting and investigating incidents led to the deficiency being cited by the surveyor.
Plan Of Correction
Element 1 Upon discovering the NJ Exec Order 26.4b1 on resident #47, immediate steps were taken to assess the injury, ensure the residents' safety, and provide appropriate care (cleaning, applying any necessary treatment). The resident was closely monitored for any further changes in condition. The Ex was promptly documented on in the resident's medical chart. On the same day, an incident report was created to ensure a complete record of the event. An in-service was completed by the Assistant Director of Nursing for all nursing staff regarding notifying the nurse immediately of any skin alterations, as well as Abuse and Neglect policy and reporting. Element 2 The standard was not met for resident #47. All residents that are at risk for skin alterations have the potential to be affected by this deficient practice. Element 3 All nursing staff were re-educated on the facility's Abuse and Neglect policies and procedures for reporting injuries and incidents. In addition, they were re-educated on the facilities abuse reporting and prevention policy. Emphasis will be placed on the importance of documenting every skin alteration. Element 4 Incident audits have been conducted weekly for the first 2 months, every other week for the next 2 months, and then monthly for the following 2 months to review compliance and to ensure all injuries are documented and reported appropriately. Identified issues will be corrected as they are discovered, results will be reported to the Director of Nursing and will be reviewed at quarterly Quality Assurance Performance Improvement meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.