Inadequate Investigation of Alleged Violations in LTC Facility
Penalty
Summary
The facility failed to ensure thorough investigations of alleged violations of abuse, neglect, or mistreatment for several residents. Resident #63, who had severe cognitive impairment and was dependent on staff for care, suffered a left shoulder dislocation. The investigation into this injury was incomplete, lacking staff statements and failing to rule out abuse, neglect, or mistreatment. The Director of Nursing acknowledged the investigation's inadequacy, noting that the x-ray results were misread, leading to a delay in addressing the injury. Resident #47, with severe cognitive impairment due to Alzheimer's disease, was observed with bruising on the face and neck. The facility's investigation did not include staff statements or determine if abuse, neglect, or mistreatment occurred. The Director of Nursing was not informed of the incident until 11 days later, indicating a significant lapse in communication and investigation procedures. Resident #81, who was cognitively intact but required assistance for daily activities, reported rough handling and verbal abuse by a Certified Nursing Assistant. The investigation did not include witness statements or follow-up with the resident, leaving the allegations unresolved. Additionally, Resident #80 experienced a medical incident where necessary medication was unavailable, and the investigation failed to identify involved staff or reasons for the medication's unavailability, highlighting a lack of thoroughness in addressing potential neglect.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 1. Immediate assessment of all residents involved to ensure safety. Residents' allegations were ruled out of neglect: mistreatment or potential abuse for residents #1, #63, #81, #80, and #103. No other residents were affected after the assessment. Injuries of Unknown Origin: Education a. Review of all reportable events. b. What is reportable? c. Process of report to DON/Administrator. 2. Process Change I. The nurse manager/nursing supervisor will obtain all statements when the event is noted. II. Discussion regarding the report done by DON and Administrator. III. The report made. IV. Investigation completed. V. A and I committee scheduled before the 5th business day to review the statement, lab, x-ray results, care plan, care card, and other potential process issues. VI. Recommendations made a. Small subgroup will meet and adjust policies and procedures as needed. b. The final report will be placed in the folder with the reportable based on the recommendations made. Review and update facility Abuse, Neglect, and Mistreatment Prohibition, Investigation, and Reporting policy. The staff has been educated regarding the process that should be taken when the emergency medication box keys concerning resident #80 or any other resident. Discussions with the Lead Pharmacist and the Consultant Pharmacist have led us to discover that some processes need to be reviewed. This meeting will occur at 11 AM on Thursday, (MONTH) 19. The agenda items include but are not limited to the following things A. What is in the current e-box for resident changes in orders? A new list will be placed in the pharmacy book that sits on each unit. B. The Narcotic E box will list available items for the provider to order and nurses to use in an emergent situation. C. Addition of the most current policies regarding the pharmacy and obtaining medication after hours. D. Update of all 3 Pharmacy books and Education will be provided to all the Nursing staff on all three units. 3. Implemented mandatory training for all unit managers and clinical coordinators on reporting and proper investigation procedures. Established a dedicated investigative team chaired by the Administrator to handle all abuse, neglect, and mistreatment investigations. The committee will recommend education based on the nature of the inquiry; all education will be completed in 30 days. The facility will initiate an investigation checklist. 4. All investigation checklists will be audited monthly for three months and presented to the QAPI committee. The committee will determine the frequency of the audit thereafter. Responsible Party: Director of Nursing