Failure to Investigate Allegations of Neglect and Mistreatment
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of neglect and mistreatment for two residents. For the first resident, a Certified Nursing Assistant (CNA) was involved in an incident where the resident fell from the bed. The CNA admitted to not asking for help despite knowing the resident required two-person assistance. The Nursing Home Administrator (NHA) did not initiate an investigation until days later, after being prompted by corporate, and failed to report the incident to the Agency for Health Care Administration (AHCA) in a timely manner. The NHA also did not interview other staff or residents at the time of the incident. For the second resident, there were multiple allegations of rough treatment by staff. The resident reported a CNA for being rough and loud, but the NHA did not thoroughly investigate the claim, failing to ask for detailed statements or interview other staff. Another incident involved a family member reporting to the Department of Children and Families (DCF) that an occupational therapist was physically shaking and yelling at the resident. The NHA did not obtain a statement from the accused staff member or conduct a comprehensive investigation. The facility's policy on prevention and investigation of abuse, neglect, and mistreatment was not followed. The NHA admitted to not obtaining necessary statements or educating staff following these incidents. The facility's failure to adhere to its own policies and procedures resulted in delayed and incomplete investigations, leaving allegations unresolved and unaddressed.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-610, Investigate/Prevent/Correct Alleged Violations Element #1. Resident #1 was assessed to ensure no further injuries, and that was at a level that was acceptable to the resident. Resident #1's care plan was updated as indicated. Resident #3 was assessed and her grievance regarding care and customer service was reviewed. The Nursing Home Administrator (NHA) and/or designee reinterviewed staff and residents and collected witness statements. The Nursing Home Administrator (NHA) and/or designee contacted the appropriate reporting agencies, the resident's primary care physician, and resident's families/responsible parties. Element #2. The Nursing Home Administrator (NHA) and/or designee conducted an audit to identify any other grievances pending completion or incomplete investigations occurring within the past 30 days. Opportunities that were identified during the audit were corrected as indicated. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no residents were by alleged deficient practices. No opportunities were identified. Element #3. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by the Regional Vice President and/or the Regional Nurse Consultant on the Reportable Investigation, and the timeliness of reporting to state authorities to ensure they understand the process of conducting a complete investigation. Element #4. The Nursing Home Administrator and/or designee will audit new grievances and reportables once a week for the next 60 days for accurate and thorough investigations. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is