Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident physical abuse to the New York State Department of Health within the required 2-hour timeframe. The incident involved two residents, one of whom hit the other on the shoulder with a grabber. The incident occurred at approximately 1:40 PM, and the facility's Administrator was made aware of it by 1:55 PM. However, the report was not submitted to the Department of Health until the following day at 12:31 PM. Resident #193, who was hit, was admitted with diagnoses including end-stage renal disease, cerebral infarction, and polyneuropathy, and was cognitively impaired. Resident #325, who committed the act, was admitted with diagnoses including Alzheimer's disease, unspecified dementia, and major depressive disorder, and was severely impaired in cognition. The incident was witnessed by a Certified Nursing Assistant who reported it to a Registered Nurse, who then informed the Assistant Director of Nursing and the Director of Nursing. Despite the facility's policy requiring immediate reporting of abuse allegations, the Assistant Director of Nursing did not receive instructions from the Director of Nursing to report the incident until the next day. Both the Director of Nursing and the Administrator acknowledged the requirement to report such incidents within 2 hours but could not recall why the report was delayed. This failure to report in a timely manner constitutes a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #193 and resident #325 were identified as being directly affected by the alleged gap in practice. The facility did not ensure that an alleged violation involving resident-to-resident physical abuse was reported immediately, but no later than 2 hours after allegations were made to the State Survey Agency. - An investigation was conducted and concluded that the altercation was sudden in nature and was not premeditated. - Resident #193 and #325 were separated. Resident #325 was transferred to another unit. - Resident #193 and #325 were assessed and monitored. - Resident #193 and #325 medical provider and family were notified of the incident. - Resident #193 and #325 were seen and evaluated by the psychologist. - Resident #325 was seen and evaluated by the psychiatrist. - Social Services provided emotional support to residents #193 and #325. - The incident was reported to the NYS-DOH on 7/29/24. - RN #4 was re-educated on actual/alleged abuse reporting to ensure that the NYS-DOH is notified within 2 hours after the incident/allegation. - CNA #7 was re-educated on abuse prevention and reporting. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All incidents and accidents for the preceding 30 days were reviewed by the Assistant Directors of Nursing to ensure that any incidents of alleged or actual abuse or incidents involving serious injury were reported timely to the DON and Administrator, as required, to the state agency and all other required agencies (i.e. law enforcement when applicable). In the event that non-compliance was identified, the incident will be immediately reported to all required entities and staff involved re-inserviced on the required timeframes to report. Responsible Party: Assistant Directors of Nursing 3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not occur? 1. The Policy and Procedure for Abuse- Prohibition Protocol, Types of Abuse, Response/Reporting Prevention/Response/Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI, and Medical Director and revised accordingly. The change in policy includes: - Any alleged violations involving mistreatment, neglect, or abuse, including serious injuries of an unknown source must be reported to the Administrator/Designee, or department director immediately. An immediate investigation must be made and the findings of such investigation must be reported to the NYSDOH via Electronic Incident Reporting form within 2 hours of occurrence/discovery. Responsible Party: Administrator, DON, Medical Director, QA/PI 2. The Policy and Procedure for Abuse Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI, and Medical Director and found to be in compliance. Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 3. Inservice education will be provided by the Inservice Coordinator/designee to all staff on abuse, neglect, and mistreatment including injuries of unknown origin regarding reporting requirements related to violations involving abuse to the NYSDOH and NYPD, immediately. Education on Abuse Prohibition Protocol will continue to be provided to staff upon hire and annually thereafter. Highlights of the lesson plan include: - The facility staff must immediately report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property to the RNM/RNS/ADON. An investigation is to immediately follow. - The RNM/RNS/ADON will immediately notify the DON who will notify the Administrator. - Upon notification, the Assistant Director of Nursing/Designee must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYSDOH and as appropriate to other required agencies (i.e., NYPD). Responsible Party: Inservice Coordinator/Designee 4. The Residents Occurrence Log-In form (SAFETY-967) was reviewed and revised to ensure that actual/allegation of abuse is reported to the NY-DOH within 2 hours of the incident/allegation. Revision of form included adding: - Reportable (Y/N) - Date/Time Reported to DOH - Date/Time Reported to Other Agency Responsible Party: QA/PI 4. How will the corrective action(s) be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility’s compliance with ensuring that all accidents and incidents are investigated, and abuse is reported timely as per NYSDOH and Federal reporting guidelines. Responsible Party: QA/PI 2. All accidents/incidents and grievances involving alleged abuse or serious injuries will be audited daily by the Assistant Director of Nursing/designee for 30 days and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Assistant Director of Nursing/Designee 3. The results of the accidents and incidents audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the accidents and incidents audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.