Failure to Report Neglect and Ensure Safe Environment
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who suffered a major injury due to an unsafe environment. The incident involved a resident in the memory care unit who experienced an unwitnessed fall in the hallway, resulting in a significant injury that required surgical intervention. The facility's policy mandates immediate reporting of such incidents, especially when they involve serious bodily injury, but this was not adhered to. The resident, who had a history of poor safety awareness and was residing in the memory care unit, tripped and fell in a hallway with rough and uneven concrete. This area was a known high-traffic zone and had a raised drain cap, which posed a hazard. Despite the known risk, the facility did not take timely action to repair the flooring hazard, which contributed to the resident's fall and subsequent injury. Interviews with facility staff, including the Director of Nursing and the Director of Maintenance, revealed a lack of prompt reporting and inadequate measures to ensure a safe environment. The Director of Nursing did not report the incident, believing the plan of care was followed, while the Director of Maintenance acknowledged the flooring issue but only addressed it after the incident occurred. The facility's failure to report the incident and address the environmental hazard in a timely manner led to the deficiency.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Nursing Home Administrator/Coordinator re-educated on ensuring that allegations of neglect or mistreatment are reported according to federal guidelines time frame. Late report completed for Resident # 6. Resident #6 no longer resides at the facility. 2. Identification of other residents having the potential to be affected: Care Plan Coordinator/Designee completed quality review of residents who sustained in past 6 months. No newly affected residents identified. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Education for all staff on Neglect and a position has been created for a facility risk manager, and we are currently recruiting for the position. A daily Risk Management Meeting initiated at daily clinical meeting, to include attendance of the interdisciplinary team with NHA oversight. Risk events including alleged violations involving possible neglect, mistreatment, injuries of unknown source and misappropriation will be reviewed by Administrator/Risk Manager/Designee to ensure all reportable events meet the time frame guidelines for reporting. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator/Risk Manager/Designee will conduct an audit of risk events to monitor all risk events for alleged violations including possible neglect, mistreatment, injuries of unknown source and misappropriation and make certain violations are reported five times a week X 4 weeks, 3 times a week X 4 weeks, twice weekly X 4 weeks, then weekly and as indicated. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.