Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for additional allegations to go unreported and delayed investigation. Resident #105, who has a history of inappropriate physical behavior and aggressive tendencies, was involved in two incidents with Resident #106. During these incidents, Resident #105 approached Resident #106 aggressively, causing fear and distress. Despite staff intervention, the incidents were not reported immediately as required by the facility's policy. Resident #106, who was the victim of Resident #105's aggressive behavior, reported feeling scared and harassed. The facility's Unit Manager and Nursing Home Administrator were aware of the incidents but did not conduct an abuse investigation or report the incidents to the state agency. The Nursing Home Administrator believed that staff were overreacting to Resident #105's behavior and did not consider the incidents as abuse. Additionally, there was an allegation of potential sexual abuse involving Resident #107, who is severely cognitively impaired. A family member reported concerns about a male staff member to the Unit Manager, but the facility did not report the allegation to the state agency or conduct a further investigation. The Director of Nursing confirmed that the facility did not report the allegation, which was a violation of the facility's policy to protect residents and report all alleged violations immediately.
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.