Failure to Timely Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure a timely and thorough investigation of an alleged abuse incident involving a resident. On December 28, 2024, a resident reported being scratched by a Certified Nursing Assistant (CNA) during morning care. However, there was no documented evidence that an investigation was initiated until December 30, 2024, when the resident's representative reported the incident to the Director of Nursing Services. The facility's policy requires that all accidents or incidents involving residents be reported immediately and an Accident/Incident Report be completed on the shift in which the incident occurred, but this protocol was not followed. The resident involved had a history of Bipolar Disorder and Urinary Tract Infection and was assessed to have moderately impaired cognition. The resident required assistance with daily activities and had no functional limitations in the range of motion. On the day of the incident, the resident alleged that a CNA squeezed their fingers and scratched their buttocks during care. Despite the resident's complaints, the initial examination by a nurse found no visible injuries, and the resident's skin was noted to be intact. The resident continued to insist on being scratched, but no immediate investigation or documentation was made by the staff present at the time. Interviews with the staff involved revealed inconsistencies in the handling of the incident. The CNAs involved denied the allegations, and the Registered Nurse who assessed the resident failed to document their findings or initiate an investigation. The Director of Nursing Services was only made aware of the situation two days later, highlighting a significant delay in addressing the resident's allegations. This delay in response and lack of documentation contributed to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F610. SW met with resident #55 on 2/28/2025 and offered psychological and psychiatric services. Resident declined the services, and resident denied any emotional distress. RN #2 was re-educated on 3/01/2025 on the policy and procedure on initiating abuse/mistreatment/neglect investigation and reporting guidelines and on proper documentation. Certified Nurses Assistant #4 and #5 was re-educated on 2/26/2025 on the policy and procedure of abuse/mistreatment/neglect and exploitation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the alleged deficient practice. Facility did an audit/review on 2/25/2025 on investigations of allegations, and no potential reportable allegations of abuse were found. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Abuse Reporting and Investigating was reviewed by DNS, Admin, and Social Worker and no updates were made. All RN Supervisors were re-educated on 3/01/2025 on the Policy and Procedure for Abuse Reporting and Investigation Policy by the DON/designee. New hires will be trained during the onboarding process. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure allegations of abuse, neglect or mistreatment are investigated immediately as required. Any adverse findings will be immediately corrected accordingly. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.