Failure to Update Abuse Prevention Policies and Employee Screening
Penalty
Summary
The facility failed to implement and update its policies and procedures to prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. During a complaint investigation and extended standard survey, it was found that the facility's abuse reporting policy, last revised in December 2015, was outdated and did not align with current regulations. Specifically, the policy did not include a timeline for notifying the New York State Department of Health about alleged violations, which is required to be reported immediately or within 24 hours depending on the severity of the incident. This deficiency affected 10 out of 12 residents reviewed. Additionally, the facility did not conduct the required New York State Nurse Aide Registry Verification for an agency Licensed Practical Nurse (LPN) before their employment. The LPN worked multiple shifts at the facility without this verification, which is a necessary step to ensure that employees are screened for any history of abuse. The lack of verification was confirmed during interviews with the Administrator and the Infection Control/In-Service Coordinator, who acknowledged the oversight and the absence of documentation for the verification process. The Director of Nursing and the Administrator admitted to being unaware of the updated regulations for reporting allegations of abuse and neglect. They relied on the Risk Management Team for investigations and expected to receive updates through official communications, which they missed. The facility's failure to update its policies and procedures in accordance with state guidelines resulted in substandard quality of care, with the potential for more than minimal harm to all residents.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 F-607 – Develop/Implement Abuse/Neglect Policies I. Per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: - Resident #17: - Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. - An assessment by a Registered nurse was completed on each altercation. No injuries were identified. - Resident #17’s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging. - A Social Services assessment completed to ensure there were no negative psychosocial impacts due to the altercations and subsequent room changes. - Resident #30: - An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #5 will be re-educated on their role to review the care plan prior to providing care. - Resident #42: - An assessment by a Registered nurse was completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #4 is no longer employed by the facility. - Resident #47: - An assessment by a Registered nurse was completed. No injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - An investigation was conducted and allegation unfounded for sexual abuse. - Certified Nursing Assistant #9 was re-educated and was re-assigned from providing care to resident #47. - Resident #68: - Assessments by a Registered Nursing and Physician were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts. - Additional signage will be placed on the resident’s door to deter others from wandering into the resident’s room. - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. - A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident. - Resident #72: - Assessments by a Registered Nursing were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there were no additional negative psychosocial impacts related to the incident. - Resident #75: - Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. - An assessment by a registered nurse was completed following each altercation. No injuries were identified. - The resident was moved to a different unit on 12/11/24. - Resident #75’s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due to possessiveness. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts related to the resident to resident altercations and the subsequent room change. - Resident #95: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Resident #161: - The resident was discharged from the facility on 7/26/24. - A review of the resident’s medical record indicates no additional injuries or negative psychosocial impacts. - Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. - Certified Nursing Assistant #4’s employment was terminated. - A New York State Nurse Aide Registry Verification report was obtained for the Employee Licensed Practical Nurse #4. No findings were noted. - The Administrator, Director of Nursing, and Assistant Director of Nursing were educated on the State Operations Manual timeframe reporting requirements for abuse reporting by the consultant. - The Administrator, Director of Nursing, Assistant Director of Nursing, and the Infection Control/In-Service Coordinator were educated on the requirement for pre-employment screening for all regular and agency staff via the New York Nurse Aide Registry by the consultant. II. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect, or mistreatment. The care plan of any identified resident will be reviewed and updated accordingly for risk of Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, and ensure interventions are initiated in an effort to prevent abuse. - Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. - All regular and agency staff personnel records will be reviewed to ensure the Nurse Aide Registry screening has been completed. III. Per the Directed Plan of Correction the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Abuse/Neglect - Prevention and Reporting Process” has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. - The facility hiring policy will be reviewed by the consultant with administration and nursing leadership and a checklist provided to ensure all pre-employment procedures including Nurse Aide Registry Checks are completed prior to starting work. - As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address: - Abuse Identification, Prevention and Reporting: All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing staff immediately to prevent further abuse, and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: The Administrator and Director of Nursing and facility leadership (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence, and immediate removal of any staff alleged to be involved. - Nurse Aide Registry: All facility leadership staff will be educated by the consultant on the updated hiring policy/process and checklist specifically to ensure the nurse aide registry is reviewed prior to hiring both regular and agency staff. - Regulatory Changes: All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. - All training components will be added to initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. - An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect, or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plans updated accordingly. - An audit tool will be developed, and all new hires will be audited weekly for 4 weeks then monthly for 3 months to ensure pre-employment screening, including the nurse aide registry has been completed before hire. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assessment & Assurance Committee monthly for three months. The consultant will participate in the Quality Assessment & Assurance Committee for three months. Frequency of ongoing audits will be determined by the Committee based on audit results. - The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly for 3 months. Responsibility: Director of Nursing