Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a nursing home staff member. This incident involved a resident who was observed with a black eye, which they reported was caused by being punched by a staff member, specifically a Registered Charge Nurse. The resident, who had intact cognition, was able to identify the staff member involved in the incident. The facility's policy on the prohibition of resident abuse was not adhered to, as the staff member did not assess the resident or report the incident to the appropriate authorities. The incident occurred when the resident was redirected from entering a dining room with a wet floor, leading to an altercation where the resident reportedly slapped the staff member. The staff member did not report this altercation or the subsequent discoloration observed on the resident's face. Multiple staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, observed the discoloration but did not take immediate action to report or assess the situation. The Director of Nursing was eventually informed by an Occupational Therapist, who noticed the resident's condition and reported it. The facility conducted an investigation and concluded that there was reasonable cause to believe that abuse had occurred. The resident consistently reported being punched by the staff member, and the staff member failed to follow protocol by not reporting the incident or assessing the resident's condition. The lack of immediate action and communication among staff members contributed to the deficiency in protecting the resident from abuse.
Plan Of Correction
Plan of Correction: Approved April 29, 2025 Element #1: What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice Residents #1 who was affected by this deficient practice was assessed by RN Supervisor (RNS), PMD and Psychiatrist. Right periorbital x-ray was ordered and result showed no fracture. Accused RN was immediately removed from duty. Completed 4/17/2025. Element #2: How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents under the care of accused RN had the potential to be affected by the deficient practice. Consequently, upon report of occurrence on 9/7/2023, the accused RN was immediately removed from duty and employment subsequently terminated. Cognitively intact residents who were under the care of accused RN will be interviewed and assessed for abuse or inappropriate interactions. Residents who are cognitively impaired, their NOK will be interviewed instead. Completed 6/3/2025. Element #3: What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Facility Abuse prevention policy and procedure was reviewed and revised to include that staff accused of abuse must be removed from duty immediately. All employees will be monitored by their respective department head to ensure they are not abusing residents. Specifically, unit CNA, LPN, and RN will be monitored by RN Supervisor. ADNS will supervise RNS for any inappropriate or abusive interactions with residents. Employees identified with behaviors or negative interactions that equate to abuse will be removed from duty immediately. All residents will be monitored by unit RN Supervisor and Social Worker to ensure they are not abused by staff. All staff who directly interact with residents—such as nursing, medical, housekeeping, social work, activities, rehabilitation, and administration—will be re-inserviced on abuse prevention by ADNS and/or their direct supervisor. Social Work Director and/or designee will attend monthly resident council meetings to educate residents on the procedure for promptly reporting abuse. DNS will monitor for sustained compliance of staff abuse prevention education and observation to ensure all residents are free from staff abuse. Completed by 5/31/25. Element #4: How the corrective actions(s) will be monitored to ensure the deficient practice will not recur—what quality assurance program will be put into practice Social Worker will audit/interview 5 residents weekly to assess comfort with caregivers and/or report of abuse and report to DNS and/or Administrator of their findings. Negative findings will be addressed promptly. ADNS will conduct weekly audits of direct staff interaction with residents on unit and report to DNS and/or Administrator of their findings; negative findings will be addressed promptly. Audit findings will be reported and reviewed at QAPI weekly x 2 weeks; monthly x 2 months, then quarterly thereafter. Completed by 5/31/2025. Element #5: The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing and/or designee Date: 6/3/2025