Failure to Investigate Allegation of Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures to investigate allegations of abuse and neglect for a resident diagnosed with Parkinson's disease, vascular dementia, anxiety disorder, muscle weakness, dysphagia, and cognitive communication deficit. The resident, who was last assessed as cognitively intact, reported that a male resident entered her room and attempted to get into bed with her, causing her fear and inability to sleep. Despite the resident's report, the Director of Nursing (DON) did not interview the resident, notify her family, or inform the Administrator of the allegation. The DON assumed that the incident was a misunderstanding involving a wandering resident and believed that placing a STOP banner across the resident's doorway was sufficient to ensure her safety. The report further indicates that the DON did not conduct interviews with other residents on the unit or take additional steps to investigate the incident. The Administrator acknowledged that such an incident might require reporting, depending on the situation. Additionally, a Licensed Practical Nurse (LPN) mentioned that while the night shift staff was aware of which residents could walk, there was no list of residents who wandered. The lack of a thorough investigation and communication with relevant parties highlights the facility's failure to adhere to its own policies regarding the handling of abuse and neglect allegations.
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. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On Resident #1 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. On Resident #1's care plan was reviewed and revised to include a stop sign on her doorway to deter any other residents from entering her room. On Social Service Director completed an assessment for resident #1. No concerns were noted related to the alleged deficient practice. On a grievance was filed on resident #1's behalf. On a thorough investigation was conducted regarding the allegation of a male resident entering resident #1's room. Results of the investigation did not rise to a level of meeting reporting criteria. On the Administrator and Director of Nursing were re-educated by the Regional Nurse Consultant on facility policy and procedures regarding reporting and investigation. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On a quality review was completed by Director of Nursing/designee on current interviewable residents regarding neglect, and with focus on other residents entering their rooms. No additional residents were found to be affected by the alleged deficient practice. On the Director of Nursing/Designee completed a quality review of current resident progress notes for the past 7 days to identify any areas of concern that may require additional investigation. No further concerns noted. On the Director of Nursing/Designee completed a quality review of facility grievances for the past 30 days for any areas of concern that may require additional investigation. No further concerns noted. On a quality review was completed by Director of Nursing/Designee of current residents to identify any resident who may have potential to enter other residents' rooms. Care plans revised as appropriate. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By current facility staff were educated on the components of F607 with an emphasis on reporting and investigation by the Director of Nursing/Designee. By current Nursing staff were educated on characteristics and redirection techniques. Newly hired nursing staff will be educated on characteristics and redirection techniques by the Director of Nursing/Designee at orientation as a part of the systematic changes. Newly hired staff will be educated on the components of F607 with an emphasis on reporting and investigation by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 10 current residents' nursing progress notes 3 times a week for 4 weeks, then 1 time a week for 4 weeks, then 2 times weekly for 4 weeks, and then weekly for 4 weeks to ensure response/investigation for any potential allegations that meet federal reporting requirements. Administrator/Designee to conduct audits of Grievances 3 times a week for 4 weeks, then 2 times a week for 4 weeks, and then weekly for 4 weeks to ensure a response/investigation for any potential allegations that meet federal reporting requirements. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.