Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for three residents, resulting in staff not reporting resident-to-resident observations of abuse to the Nursing Home Administrator (NHA) immediately, the facility not initiating a thorough investigation, and the facility not reporting allegations of abuse to the state agency. This deficiency involved Resident #105, who had a history of inappropriate physical touching and aggressive verbal behaviors, and Resident #106, who was the target of Resident #105's aggressive actions. Despite staff interventions during incidents where Resident #105 approached Resident #106 aggressively, the incidents were not reported immediately, and no investigation was initiated. Resident #105, who was cognitively intact, exhibited aggressive verbal behaviors towards Resident #106, causing fear and distress. Staff members, including an LPN and a Physical Therapy Assistant, witnessed these incidents and intervened to redirect Resident #105. However, the incidents were not documented or reported to the NHA immediately. The NHA did not conduct an abuse investigation, believing the staff's reactions were overly reactive and that Resident #106 was not significantly affected. This inaction led to a failure in addressing the potential abuse and ensuring the safety of Resident #106. Additionally, concerns were raised about potential sexual abuse involving Resident #107, who was severely cognitively impaired. A family member reported these concerns to a Unit Manager, but the facility did not investigate further or report the allegations to the state agency. The Director of Nursing confirmed that the facility's abuse policy was not followed, as there were no obvious signs of injury, and the resident stated they felt safe. This lack of action and failure to follow the facility's abuse policy resulted in the deficiency noted in the report.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.