Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect Resident #1 from abuse when a staff member, Registered Nurse #2, allegedly twisted the resident's wrist and removed their call light. Resident #1, who has quadriplegia and is cognitively intact, reported the incident, which resulted in a reddened area and bruising on their wrist. The care plan for Resident #1 included ensuring the call bell was within reach and temporarily interrupting care if the resident became verbally abusive, which was not followed by the staff member involved. Resident #14, who has severe cognitive impairment due to dementia, experienced neglect when a Certified Nurse Aide provided care without the required assistance of a second staff member, as outlined in the resident's care plan. This neglect led to a fall from the bed because the bed bolster was not in place, although no injuries were reported. The care plan specified the use of posey rolls and a two-person assist for bed mobility, which were not adhered to during the incident. Resident #23, also severely cognitively impaired, suffered a skin tear on their hand due to the actions of Certified Nurse Aide #3, who failed to follow the care plan requiring two staff members to assist when the resident was resistive to care. The aide was observed grabbing the resident's hands, leading to the injury. The care plan emphasized allowing time for the resident to de-escalate and re-approaching if agitated, which was not followed, resulting in the resident's injury.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #1 had a skin check completed by registered nurse. Skin check revealed reddened area to wrist on 6/23/2024. Director of Nursing was notified on 6/23/2024. Administrator was notified per policy on 6/23/2024. Registered Nurse #2 was immediately placed on administrative leave and removed from facility pending investigation on 6/23/2024. Department of Health notified on 6/23/2024. Provider ordered diagnostic studies on 6/24/2024 which revealed no fractures. Registered Nurse #2 was terminated from employment on 6/26/2024 and Office of Professions notified of incident. B. Resident #14 had a recorded witnessed fall on 12/22/2024 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024. Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024. Resident #14 sent to emergency room on [DATE] and returned on 12/22/2024 with no findings. Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. C. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024. Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024. Registered Nurse #4 was educated/reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. Certified Nurse Assistant was placed on administrative leave on 12/25/2024. Certified Nurse Assistant was terminated on 12/27/2024. 2. Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency. A review of all residents with behavior care plans was completed on 02/21/2025. One additional resident was identified as requiring 2 assists with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention, Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18, 2025. Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. The Abuse Reporting and Investigation policy was reviewed on 2/10/2025 with no changes. C. There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee.