Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations of abuse, including injuries of unknown origin, to the state survey agency within the required two-hour timeframe for two residents. Resident #110, who had diagnoses including heart failure, dementia, and atrial fibrillation, was found with a bruise on 10/27/24. The injury was reported to the floor nurse on the same day, but the state agency was not notified until 10/30/24. The Director of Nursing, who was on vacation at the time, acknowledged the delay and stated that an investigation was initiated, but the findings were inconclusive. The Medical Director noted the resident's high risk for bruises due to their medical history but was unaware of the reporting delay. Resident #186, with diagnoses including dementia and a history of breast cancer, was found with a forehead hematoma and cheek injuries on 1/12/25. The resident was unable to explain the cause of the injuries, and the state agency was not informed until 1/16/25. The Director of Nursing confirmed the delay in reporting, and the Administrator acknowledged the requirement to report such injuries within two hours. These incidents indicate a failure to adhere to the facility's policy on timely reporting of suspected abuse or injuries of unknown origin.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? To correct the deficient practice we reviewed all incidents for the last 90 days and identified any incidents of abuse that were not reported timely. Staff member was disciplined for failing to report incident on 1/12/25 timely to the ADON on call. Staff will also be re-educated on purposeful rounding and monitoring skin integrity during the performance of ADLs. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. All incident and accidents reports for the last 90 days were reviewed for timely reporting. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? The Policy was Reviewed and found to be in compliance. To prevent the deficient practice all staff members including clinical and non-clinical staff will receive training and education on reportable incidents and policies Patient Incident Management, and Abuse, Neglect, Mistreatment Prevention. This training will also include immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown origin. Nurse supervision will conduct frequent rounding each shift to ensure that residents are in safe environment and not subjected to abuse, neglect, and mistreatment. During the rounding nurse supervisor will remind staff that all allegation of abuse, incident of mistreatments, injuries of unknown origin should be promptly reported. An on-call monthly schedule for ADONs/DONs will be posted in the nursing office for call support to ensure all incidents are reported timely to the DOH. Nurse supervisor will contact on call nursing leadership to facilitate timely reporting of all allegations of abuse neglect, or mistreatment within two hours. It is responsibility of the DON and/or designee to ensure timely reporting all incidents involving injuries of unknown origin and allegations of abuse. The training will be providing by the Nurse Educator and/or designee. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? The DON, or designee, will review nursing shift report, nursing documentation, and clinical alerts to ensure any injuries are identified, properly investigated and reported to the appropriate people daily x 2 weeks and then weekly x 1 month and monthly thereafter. Results will be provided to QAPI for action as appropriate.