Failure to Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin and an allegation of physical abuse involving a resident with severe cognitive impairment. The resident, who was admitted with vascular dementia and required 1:1 supervision due to aggressive behaviors, was involved in an incident where a nurse aide allegedly restrained the resident inappropriately. Despite conflicting accounts from staff members, the facility did not suspend the involved employee immediately, as required by their abuse prevention policy, nor did they conduct a comprehensive investigation to rule out abuse, neglect, or mistreatment. The incident occurred when a nurse aide was observed holding the resident in a chokehold while attempting to remove the resident from behind the nurse's station. An altercation between staff members ensued, involving yelling and profanity in the presence of residents and staff. The facility's failure to ensure immediate protective measures and consistent supervision of the resident highlighted systemic deficiencies in safeguarding residents from potential abuse and maintaining a safe environment. Additionally, the facility did not investigate a bruise found on the resident's hip, failing to interview relevant staff or document witness statements as required by their policy. This lack of investigation into the injury of unknown origin compromised the facility's ability to identify and address potential abuse, neglect, or mistreatment, thereby jeopardizing the safety and well-being of residents under their care.
Plan Of Correction
- A16 investigation and follow-up completed on 1/23/25. A16 chart review completed and plan of care reviewed and updated to include behavior management plan to meet his individual needs. Staff involved in the investigation were re-educated on the facility policy and appropriate action taken per facility policy for the employees. - Facility wide audit completed on current residents to rule out any allegations of abuse, neglect or mistreatment. The facility will implement a new screening process for potential residents who require the memory support unit and appropriateness of admitting to the unit. - Immediate staff re-education provided to the administrative team related to the policy entitled, "Resident to Freedom from Abuse, Neglect, and Exploitation." 2/3/2025. All other facility staff mandatory education to be completed by directed in-service on 2/11/2025. This training shall include recognizing signs and symptoms of potential abuse, including bruises of unknown origin. Proper reporting protocols and the process for conducting a thorough internal investigation. New employees will also receive this training as part of their onboarding with annual refresher training. - Root Cause Analysis conducted in conjunction with QAPI and governing body and incorporated into the intervention plan (POC). - The DON or designee will conduct daily audits for any allegations of abuse and/or neglect for 3 months, then weekly for 4 weeks, then monthly for 2 months. - Findings will be reported to the QAPI Committee monthly for ongoing oversight. - Leadership will conduct unannounced compliance audits to ensure reporting and investigation processes are being followed. - The facility will seek feedback from residents and families through random interviews and resident council meetings to ensure a culture of safety.