Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to prevent further abuse and did not timely and accurately report allegations of abuse to the State Agency for two residents. Resident #7, who was cognitively impaired and dependent on staff for personal hygiene, filed a grievance about being verbally abused by a CNA. The grievance was not reported to the State Agency, and the facility's Administrator was unaware of the grievance until it was brought to her attention during the survey. The grievance was not investigated as required, and the incident was not included in the facility's Reportable Event Log. Resident #1, who was cognitively intact but required assistance for personal hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The incident was reported to the facility's Director of Nursing (DON) and the Weekend Supervisor, but the investigation was inadequate. The facility did not collect witness statements from all involved staff, and the DON did not follow up on the investigation. The facility's report to the State Agency was delayed, and the investigation folder lacked necessary documentation, such as witness statements and progress notes. The facility's policy on abuse, neglect, and exploitation was not followed. The policy required immediate segregation of the suspect from residents, a thorough nursing evaluation, and timely reporting to the State Agency. However, the facility did not perform a head-to-toe assessment on Resident #1, and the investigation was not conducted thoroughly. The facility also failed to provide emotional support and counseling to the residents involved, as outlined in their policy.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by Executive Director (ED). On Resident #1 reported was submitted to AIRS system by the Executive Director (ED). (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. An audit was conducted on all residents with a of 11 or higher for potential reportable events. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff in regards to the grievance and reporting process, postings and placement of grievance forms, reporting events timely to meet 2 hour post allegation window, and 24 hours for events that do not involve or serious bodily injury. 3. All grievances are reviewed by ED, SSD and DON daily, supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. All investigations will be reviewed by RVPO and RDCS for thoroughness, accuracy and timeliness. 5. A quality review is conducted weekly by ED, DON, and SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director or designee of grievances and reportable incidents to ensure a thorough investigation was completed and to ensure the policy and process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.