Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving staff and residents. In the first incident, a security guard physically restrained a resident by grabbing their collar and holding them against a wall. This occurred after the resident attempted to exit through an emergency door, and the security guard reacted to being punched by the resident. The incident was captured on surveillance video, although the footage was unclear. Staff members present during the incident confirmed the security guard's actions, and the resident was subsequently transferred to a hospital for evaluation. In the second incident, a certified nursing assistant (CNA) was reported to have hit a resident during personal care. The resident, who had a history of aggressive behavior, attempted to kick the CNA, who then allegedly struck the resident's hand. A registered nurse present during the incident corroborated the account of the CNA hitting the resident. The resident was assessed afterward, with no visible injuries or complaints of pain, but the incident was still classified as physical abuse. Both incidents highlight a failure in the facility's policy to prevent abuse and ensure the safety of residents. The facility's investigation into these events confirmed the occurrence of physical abuse, as staff statements and video evidence supported the allegations. The involved staff members were removed from their duties pending further investigation, but the incidents underscore significant lapses in maintaining a safe environment for residents.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. **Corrective Action for Affected Resident/Area** A. Immediately after the incident, Resident #1 was assisted to safety on the Unit for RN Assessment. Resident #1 refused the body check, but the Supervisor reported that no visible injury was noted and there were no complaints of pain. The Designated Representative was informed and the Physician ordered to transfer the Resident out to the Hospital for further evaluation of uncontrolled agitative behavior. The Security Guard, who did not follow the Facility’s Policy and Procedure for “Abuse Prohibition,” was immediately removed from duty and his assignment at the Home was terminated by the Contract Vendor. B. Immediately after the incident, Resident #4 was assessed by the RN. There were no visible signs of injury or complaints of pain reported. The Certified Nursing Assistant who did not follow the Facility’s Policy for “Abuse Prohibition” was immediately removed from direct Resident care duties and placed on Administrative Leave pending an Investigation. II. **Identification of other Areas/Residents Potentially Affected** The Facility respectfully states that no other residents were identified with Abuse, Neglect, or Mistreatment concerns. The Director of Nursing/Designee performed an Audit of all other residents, to ensure that they have an Abuse Prevention/Prohibition and Resident Centered Care Plan in place. Any Resident identified with missing alleged Abuse Care Plans will be promptly updated. The Facility will provide comprehensive “Abuse prohibition” re-training for all staff members to effectively manage and support residents exhibiting behaviors associated with dementia and other behaviors. Rein-service/Competency will continue until all employees are re-trained. III. **Address what measures will be put in place or Systemic Change made to ensure that the Deficient practice will not Recur/System change and Measure to prevent Recurrence** The Facility changed the Systems for monitoring “Abuse Prohibition” to include a process that during Shift Change Huddles, the Charge Nurse will also reinforce adherence to the “Abuse Prohibition” Policy and practices and remove triggers for residents who have potential for escalating verbal outburst or violent physical aggression. The Home will select front-line staff to serve as ambassadors in specialized Dementia Care and Behavioral Management, who will provide support and guidance to other team members. The Facility’s Policy and Procedure for “Abuse Prohibition” was reviewed by the Acting Administrator and was found to be compliant. All current employees will be rein-serviced immediately on the Policy and annually thereafter. New employees will be In-service during Orientation. Lesson Plan will include, but will not be limited to: - The Facility will not knowingly and intentionally hire individuals found guilty of Abuse, Mistreatment of [REDACTED]. - Employees shall adhere to the reporting mechanism as outlined in the law and regulations. - Employees are made aware that any derogatory language or remarks towards Residents and any other potential Abuse, Neglect issues will lead to immediate suspension/termination. - The Facility will train staff to safely care for combative residents, emphasizing de-escalation techniques and ensuring that they do not retaliate to physical aggression. - The Facility requires that Potential Abuse cases are reported and investigated immediately once brought to the attention of a Supervisor. - Employees are instructed on appropriate and safe interventions of care to be used with aggressive residents with behaviors. - Employees shall report occurrences that may be interpreted as acts of Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. - Ensuring staff understanding of Residents’ behaviors that could lead to physical violence, and Behavioral Management measures to de-escalate such behaviors. - Licensed staff members are educated on how to document and fully describe unusual events that could be interpreted as a situation of Potential Abuse. - Administrative Management and Supervisory personnel monitor staff interaction with residents on an ongoing basis to ensure residents’ safety. In-service and Competencies will be filed in the employees Personnel History Folder for reference and validation. IV. **How does the Facility plan to monitor its performance to make sure that Solutions are Sustained/Monitoring of Corrective Actions** The Director of Nursing and the Director of Social Services developed an “Abuse Prohibition Compliance Audit Tool” to identify high risks resident for alleged potential abuse, and staff interventions for such behaviors. The Audit Tool will be used Daily by the Associate Director of Nursing/Designee and the Social Workers/Designee, to monitor and document alleged cases of Potential Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. Any case found out of compliance will warrant an immediate on the spot correction/rein-service by the Supervisor, followed by a formal Report, employee Statements, and an Investigation. The Director of Nursing and the Director of Social Services will review the Audit Tool Weekly for compliance. The Tool will be filed in a Binder in the Nursing Administration Office after it is reviewed, for reference and validation. **IV. QA Monitoring** The person responsible to correct this issue is the Director of Nursing and the Director of Social Services. The Associate Director of Nursing/Designee will report findings Monthly to the QAPI Committee for 12 Months.