Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin within the required timeframes to the State Agency, as mandated by federal and state regulations. Specifically, incidents involving several residents were not reported within the two-hour window for abuse allegations or the 24-hour window for neglect and non-abuse related injuries. This deficiency was identified during a complaint investigation and extended standard survey, affecting 10 out of 12 residents reviewed. One significant incident involved a resident who reported inappropriate touching by a Certified Nurse Aide during incontinent care. The allegation, considered sexual abuse, was not reported to the State Agency within the required two-hour timeframe. Another incident involved a resident-to-resident altercation resulting in physical injuries, which was also not reported promptly. Additionally, there were multiple instances where care plan violations led to injuries, such as skin tears, which were not reported within the required 48-hour period. The facility's outdated policy and procedures, last updated in 2015, contributed to the failure to comply with current reporting regulations. The Director of Nursing and Administrator were unaware of the updated guidelines, leading to delays in reporting incidents to the State Agency. This lack of timely reporting resulted in substandard quality of care, with the potential to affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 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 Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging care plan with appropriate interventions to prevent recurrence. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - 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. - The resident’s care plan will be reviewed and updated to include risk for Physically/Verbally Aggressive behaviors and appropriate interventions to reduce risk. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts. - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be reviewed and updated to include wandering risk, risk for victimization due to wandering and behaviors directed at others. - 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 upon each altercation with resident #17. No injuries were identified. - 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. - Resident #75 was moved to a private room on a different unit. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts related to the resident to resident altercations. - 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. - The Administrator, Director of Nursing, and Assistant Director of Nursing were educated by the consultant on the State Operations Manual timeframe reporting requirements for abuse reporting 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. 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. - 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 any staff alleged to be involved immediately to prevent further abuse, and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: - The Administrator, Director of Nursing, and facility leadership staff (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. - All training components will be added to the 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. - 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. - 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 x 3 months. Responsibility: Director of Nursing