Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The facility's policy requires that any incident of abuse be reported immediately to the Executive Director or designee and thoroughly investigated. However, the facility did not adhere to this policy when a resident reported being assaulted in her genitalia. The resident, who had diagnoses including chronic kidney disease, heart failure, and anxiety disorder, reported the alleged assault to a physician on January 9, 2025. Despite the report, there was no documentation of a physical assessment of the resident's genitalia, and the allegation was not reported to the facility's administration. The physician's progress notes from January 9 and January 14, 2025, documented the resident's allegations of being assaulted and having delusional thoughts. However, the facility staff, including a Licensed Practical Nurse, did not recall any specific comments regarding the alleged assault. The physician believed the resident's thought content was delusional, and no physical examination was conducted to investigate the claims. The lack of immediate reporting and investigation of the resident's allegations was a significant oversight. The Assistant Director of Nursing discovered the documentation of the alleged assault during a clinical meeting on January 22, 2025. It was only then that an investigation was initiated. The Nursing Home Administrator confirmed that neither she nor any other administrative staff were made aware of the resident's allegations on January 9 or January 14, 2025. This failure to report and investigate the allegations promptly was a violation of the facility's policy and regulatory requirements.
Plan Of Correction
R1's initial allegation documented on 1/9/25 was identified by the facility on 1/14/25, and reporting requirements to the Department of Health, Area of Aging, Local Police, and the PA Department of Aging occurred immediately. 2. The Executive Director spoke with E2 and the Medical Director about reporting immediately any allegations of abuse/neglect. An audit was conducted of Physician progress notes dated 12/9/24-1/30/24. No other documented allegations of abuse were identified. 3. UPMC Post Acute Providers and facility staff will be re-educated by the Executive Director on immediate abuse reporting requirements. Physician Progress notes will be reviewed during daily clinical meetings for three months to ensure that there are no entries of risk, including allegations of abuse that have been unreported to the facility. 4. Weekly random audits of physician progress notes conducted by the Executive Director or designee of at least 5 residents will occur x 3 months to validate any documented allegations have been immediately reported to the Executive Director. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or recommendation.