Failure to Report Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to report allegations of neglect and mistreatment involving a resident to the State Agency and did not protect the resident during the investigation. The resident, who had been in the facility for over two years, reported 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 nurse, who only spoke English, about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with other medications, which the resident refused to take. The resident requested to speak with a supervisor, but the nurse did not comply and left the room. The following morning, the resident reported the incident to the MDS Coordinator, who arranged for a Spanish-speaking staff member to assist with communication. The Director of Nursing (DON) and the night nurse 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. The resident expressed fear of retaliation and reported previous issues with staff not providing timely personal care. Despite the resident's request not to have the same nurse assigned to her, the nurse was reassigned to her care, causing further distress. The facility's reportable log did not include the resident's allegations, and the Administrator (NHA) was unaware of the DCF's visit concerning the resident's complaints. The NHA and DON did not initially report the incident as neglect, and the facility's policy on reporting and investigating allegations was not followed. The DCF Investigator confirmed discussing the allegations with the facility, but the NHA claimed not to have been informed of the specific reasons for the DCF's visit. The facility's failure to report and investigate the allegations properly resulted in a deficiency in meeting regulatory requirements.
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 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 . F 609