Failure to Investigate Abuse Allegations in LTC Facility
Penalty
Summary
The facility failed to ensure all allegations of abuse were thoroughly investigated for three residents. In the first incident, video surveillance footage revealed that a Certified Nurse Aide (CNA) pushed a resident to the floor, resulting in a fractured hip. Despite the incident being captured on video, there was no documented evidence that the facility initiated an investigation on the day of the incident. The CNA was allowed to continue assisting the resident after the fall, and the facility did not take immediate measures to prevent further potential abuse. In the second incident, a resident was left unattended in the bathroom by another CNA for one hour and twenty minutes, leading to a fall and injury. The facility did not review the surveillance footage until three days later, and there was no documented evidence of measures taken to prevent further potential abuse by the CNA. Additionally, the facility did not submit a 5-day Investigation Report to the New York State Department of Health. The third incident involved verbal abuse, where a CNA yelled at a resident to sit down. The facility was first made aware of the incident two days later, and there was no documented evidence of measures taken to prevent further abuse by the CNA. The facility's investigation deemed the allegation likely, but there was no documented evidence of corrective action for other staff members involved in the incident.
Plan Of Correction
Plan of Correction: Approved March 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction. **Element 1** Resident 1 was provided with medical intervention at the time of the incident. Resident is being monitored for any psychosocial stressors related to this event. The resident's medical record was reviewed to determine if any changes to routine patterns were documented; none identified. Law enforcement was notified of the event. Resident 2 was discharged on [DATE]. Staff involved are no longer at the facility. A full investigation was completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25. Resident 3 is being monitored for any psychosocial stressors related to this event. The resident's medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented; none identified. A full investigation was completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25. **Element 2** All residents have the potential to be affected by the stated deficiency. All residents that reside in the facility will be interviewed by social work to determine if they feel safe in the facility. Any concerns will be investigated and reported as required. Nursing and social work will monitor the identified residents for potential adverse effects related to allegations (e.g., mood/behavioral changes, changes in daily routine, etc.). The past 30 days of Incident Reports were reviewed by the Director of Nursing to determine the thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrence. Review will be completed by 3/27/25. No follow-up action required. All staff were in-serviced by the nursing educators on 2/12/25 - 2/13/25 on the investigation of allegations of abuse, neglect, and mistreatment. **Element 3** Measures taken to ensure the problem does not recur: The Abuse Reporting/Investigation policy and procedure were reviewed by the Administrator, Director of Nursing, and Nursing Administration. The abuse reporting/investigation policy changed to reflect the need to report immediately but not more than two hours for all allegations of abuse, neglect, and mistreatment. Supervisors have been educated on the process to report and given standard work instructions outlining the process. This includes the following: - Notify Administrator - Notify Director of Nursing - Submit report to Department of Health - Notify Law Enforcement Social work, nursing supervisor, nurse manager, assistant director of nursing, director of nursing, and administrator were educated on completing the Investigation Checklist for Allegation of Resident Abuse, Neglect, or Mistreatment contained in the Abuse Reporting Policy. By completing all elements of the checklist, it will provide a thorough review of the incident and the ability for staff to make appropriate corrective actions to prevent reoccurrence of the event. The review of the Investigation Checklist includes, but is not limited to, the following: - Notification of Administrator and Director of Nursing - Accused removed from assignment/suspended until investigation complete - Incident Report/Resident Statement - Statement of accused/witness statements - Face sheet/[DIAGNOSES REDACTED] - Residents' most recent History and Physical - Current physician's orders [REDACTED] - Progress notes - Care plan related to incident/Kardex reviewed or revised - Brief interview for mental status assessment - Most recent Minimum Data Set - X-ray reports - Staffing assignments - Copy of acknowledgment of submission to Department of Health - A record of interviews - An explanation of evidence reviewed - Police report if appropriate per Elder Justice Act - The conclusion reached based on above elements and data points collected during the investigation. The conclusion is drawn following a thorough and complete investigation where critical thinking is used to review the investigation and determine actions that need to be taken to prevent reoccurrence of the incident. The above education will be repeated yearly and is part of onboarding for previously identified staff. All open investigations will have a shift-to-shift handoff to the next senior leader (supervisor, director of nursing, administrator, or designee) to continue the investigation until all elements are complete to ensure the investigation is completed and closed. Any step in the process missed by staff involved in the investigation will receive immediate re-education by the administrator or designee. **Element 4** The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: The Administrator or designee will update and maintain the Investigation Log at the time of each event to ensure that the facility appropriately responds to and investigates allegations of potential misconduct per policy. The log will document elements including, but not limited to, the following: 1. Date incident reported 2. Resident demographics 3. Type of event 4. If reportable, reported within time frame 5. Investigation checklist completed 6. Conclusion 7. If any deficient practice identified, remediation/education provided The log will be audited by the Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and re-education provided. Audits will continue weekly for three months. The log will be brought to the Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. The Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy, or education based on results of audits. The committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance.