Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse, neglect, or mistreatment was reported immediately, or within two hours, to the administrator. This deficiency was evident in the case of one resident who was observed with their wrists tied to bed rails using bed sheets on multiple occasions. Certified Nursing Assistants (CNAs) observed these restraints and reported them to Licensed Practical Nurses (LPNs), but the LPNs did not escalate the report to the Registered Nurse Supervisor or the Administrator as required by the facility's policy. The resident involved had a history of moderately impaired cognition and was admitted with various diagnoses. The facility's investigation revealed that restraints were indeed used, and abuse occurred. Photographic evidence provided by the resident's family corroborated the use of restraints on specific dates. Despite the CNAs reporting the incidents to the LPNs, the LPNs failed to take appropriate action, and the Administrator was not notified until much later, when the Director of Nursing was informed by the resident's family. The facility's policy on abuse, mistreatment, and neglect required immediate reporting of any changes in a resident's condition to a Nurse Manager or Supervisor, who would then verify the concerns and initiate a report. However, the policy did not specify who should be notified in cases of suspected abuse. This lack of clarity contributed to the failure to report the incidents in a timely manner, resulting in a deficiency citation for the facility.
Plan Of Correction
Plan of Correction: Approved January 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 609 Reporting of Alleged Violations 10 NYCRR 415.4(a)(2-7) 483.12(c)(1)(4) Reporting of Alleged Violations I. The Following actions were accomplished for the resident identified in the sample: Report was made to the State Agency on 12/10/2024. Resident #1 was immediately assessed by the registered nurse; resident was sent to Brookdale hospital on [DATE] for further evaluation and treatment. The NYSDOH State investigator who was assigned to the case was informed of the allegation of abuse. The New York State Attorney General’s Office was notified on 12/11/24 and the New York City Police Department was notified on 12/12/2024. Upon return from the ER on [DATE] to the facility, a full body assessment was completed for resident #1 with no additional concerns to be reported. Resident #1 was placed on 1:1 monitoring for safety monitoring. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: A full body assessment was conducted on all residents to ensure no other resident has any injury of unknown origin which needs to be reported to the DOH. Facility held AD H(NAME) QAPI Committee meeting on 12/10/24; the areas of focus were reportable incident, resident’s rights, abuse, neglect and mistreatment, and on 12/12/24 another AD H(NAME) QAPI was held addressing resident’s safety. The Social Work interviewed alert and oriented residents to see if any resident has witnessed abuse or has ever been abused or witnessed abuse with no other resident being impacted by this practice. A risk for abuse audit was done to ensure no other resident was impacted by this deficient practice. No other residents were identified. III. The following system changes will be implemented to assure continuing compliance with regulations: Facility Director of Nursing, Administrator/Designee will audit resident [MEDICATION NAME] weekly for three months to ensure all allegations of abuse, neglect, exploitation, or mistreatment are reported timely to the DOH, adult protective service, and law enforcement in accordance with facility policy and procedure and regulatory agencies. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Nursing and the facility administrator will report results of the audit to the Quality Assurance Performance Improvement Committee for further review and recommendations for three months. The QAPI committee will make recommendations for ongoing monitoring. The Director of Nursing, Administrator/Designee will be responsible for the implementation of this plan of correction.