Failure to Prevent Resident Abuse
Penalty
Summary
The facility's administration failed to effectively utilize its resources to ensure the safety and well-being of its residents, resulting in the sexual abuse of one resident. The investigation revealed that the nursing home administrator (NHA) and the director of nursing (DON) did not fulfill their essential job duties, which include ensuring resident safety and adherence to regulatory guidelines. The job descriptions for both the NHA and DON emphasize the importance of managing safety, responding to resident concerns, and preventing abuse, neglect, and exploitation. However, these responsibilities were not adequately executed, leading to the cited deficiencies. The deficiencies were identified under the Code of Federal Regulatory Groups for Long Term Care, specifically related to the Freedom from Abuse, Neglect, and Exploitation. The facility failed to develop and implement effective policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents. Additionally, there was a lack of evidence that alleged violations were thoroughly investigated, and measures were not taken to prevent further potential abuse while investigations were in progress. The failure to report the results of investigations to the appropriate authorities within the required timeframe further highlights the administration's shortcomings in maintaining resident safety.
Plan Of Correction
1. Accused perpetrator suspended. Employee who left resident to obtain assistance suspended. Investigation completed. Nursing agency was notified. Abuse policy reviewed and revised. The facility staff educated on the Abuse Policy protecting the resident's safety which includes remaining with the resident, guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The NHA and DON will be educated by the Regional Director of Operations or designee on their job descriptions. The NHA and DON will participate in the directed education to include a review of the federal regulation citation F600 and the accompanying guidelines for these regulatory requirements. 4. The Regional Director of Operations or designee will review facility incidents weekly for 12 weeks to ensure compliance and report findings to the facility QAPI Committee.