Failure to Report Allegation of Neglect and Maintain 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 was ambulating in the hallway and experienced a fall, resulting in a significant injury that required surgical intervention. The resident's care plan indicated a risk for falls due to poor safety awareness and other factors, yet the environment was not maintained free of hazards, contributing to the incident. The investigation revealed that the resident tripped in a high-traffic area with rough and uneven concrete, which had a raised drain cap. This area was located near the dining room, nurses' station, and the resident's room. Despite being a known hazard, the facility did not adequately address the flooring issue in a timely manner. The Director of Maintenance had attempted temporary fixes, but the area remained a risk, and the facility's response was insufficient to prevent the incident. Interviews with staff indicated that the incident was not reported as an adverse event because the plan of care was followed, despite the resident suffering a significant change in condition. The facility's policy required immediate reporting of such incidents, but this was not adhered to. The Director of Nursing and other staff members were aware of the incident but failed to report it to the appropriate authorities within the required timeframe.
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.