Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident within the required timeframe. On December 25, 2024, at 2:00 AM, a staff member observed a Certified Nurse Aide (CNA) improperly handling a resident, resulting in a skin tear on the resident's right hand. The resident, who was admitted with dementia, atrial fibrillation, and anxiety disorder, was severely cognitively impaired and rarely understood by others. Despite the incident being documented in an accident report, it was not reported to the New York State Department of Health until December 26, 2024, at 3:19 PM, exceeding the mandated 2-hour reporting window for incidents involving bodily injury. The facility's policy on abuse prevention, investigation, and reporting, revised in August 2024, requires that incidents resulting in bodily injury be reported within 2 hours. However, the incident was not brought to the attention of the facility's administrator until 2:30 PM on December 25, 2024, and the CNA involved was subsequently suspended. The delay in reporting was acknowledged by the administrator during an interview, who stated that they should have been informed sooner. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements.
Plan Of Correction
Plan of Correction: Approved February 6, 2025 1. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand. Registered Nurse #4 applied steri strips to skin tear on right hand. Registered Nurse #4 was reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. 2. Other residents do have the potential to be affected by alleged deficiency. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff will be 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 will include a 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. C. The Abuse Prevention, Reporting and Investigation Policy was reviewed. 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