Failure to Report Allegations of Neglect and Protect Resident
Penalty
Summary
The facility failed to report allegations of neglect and protect a resident during an investigation. A resident, who had been at the facility for over two years, experienced an incident where a nurse attempted to administer a discontinued medication and another medication that the resident preferred to take every other night. The resident, who primarily spoke Spanish, tried to communicate with the English-speaking nurse about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with the other medications. The resident refused to return the pills until she spoke with a supervisor, but the nurse left without calling one. The resident reported the incident to the MDS Coordinator the following morning, who then informed the management. The Director of Nursing (DON) and the nurse involved confronted the resident, allegedly yelling and calling her a liar. The resident felt disrespected and reported the incident to the Department of Children and Families (DCF), who visited the facility and took pictures of the pills. Despite the resident's request not to have the same nurse assigned to her again, the nurse was reassigned to her, causing the resident distress and fear of retaliation. The facility's reportable log did not show any neglect allegations reported by the resident. The Administrator acknowledged the DCF visits but did not consider the incidents as neglect, citing the time frame of care as a factor. The facility's policy on neglect and abuse was not followed, as the allegations were not reported to the State Agency, and the resident was not protected during the investigation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Upon identification of the deficiency, the facility immediately self-reported the allegation to the State Agency. The accused nurse was removed from the schedule pending an investigation. Resident #56 was assessed by social services to ensure emotional and physical well-being. Supportive interventions, including psych services and reassurance, were provided. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of grievances for the last 60 days was conducted by the Interdisciplinary Team, which included the Administrator, Social Services, DON, RVP, and Regional Nurse to determine if any other allegations of neglect had been unreported or inadequately investigated. Any identified concerns were immediately self-reported and addressed. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Coordinator and Director of Nursing were educated on by the RVP on reporting requirements utilizing FHCAs Decision Tree. Starting on all staff will receive mandatory training on identification, mandatory reporting, and investigation protocols. All staff will be in-service by. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will conduct audits of five grievances per week for two months, followed by ten grievances per month for a minimum of three additional months, to ensure appropriate reporting and implementation of protective actions. Results of the audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. (e) The date of compliance is.