Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse, neglect, and mistreatment incidents involving four residents. The incidents included physical abuse resulting in serious injuries, such as a broken leg and shoulder, and verbal abuse. The facility's policy mandates immediate reporting of such incidents to the New York State Department of Health and other relevant authorities, but this was not adhered to. For instance, an incident involving a resident who sustained a broken hip was not reported until the following day, and another incident involving a broken shoulder was reported four days later. The facility's staff, including the Assistant Director of Nursing and other nursing staff, did not follow established procedures for investigating and reporting these incidents. In one case, a resident was left unattended on a toilet for over an hour, resulting in a fall and injury, but the incident was not reviewed or reported promptly. Video surveillance footage, which could have provided immediate evidence, was not reviewed until days after the incidents occurred. This delay in action and reporting compromised the facility's ability to provide a safe environment for its residents. Interviews with staff revealed a lack of immediate response and investigation into the allegations. Staff members reported incidents to their superiors, but there was a delay in initiating investigations and notifying the facility's administration. The facility's failure to report these incidents in a timely manner is a violation of regulations and policies governing resident abuse, which require immediate action to protect residents and ensure their safety.
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 on (MONTH) 21, 2025, to determine if any changes to routine patterns were documented; none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact (i.e., withdrawal, decrease appetite, change in sleep patterns) due to this event. Resident 2 was discharged on [DATE]. 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. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact (i.e., withdrawal, decrease appetite, change in sleep patterns) due to this event. Resident 4 was interviewed on 3/20/25 to determine if they feel safe in the facility. Resident stated she does. Resident will be monitored and observed for any signs of psychosocial stressors related to this incident. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact (i.e., withdrawal, decrease appetite, change in sleep patterns) due to this event. Staff cited in deficiency are no longer employed by the facility and appropriate referrals made to law enforcement and/or Office of Professional Discipline. **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 or designee to determine if they feel safe in the facility. Any concerns will be investigated and reported as required under New York State Department of Health reporting requirements. Interviews will be completed by (MONTH) 26, 2025. For any resident who is unable to be interviewed, the responsible party will be contacted to determine any concerns. These contacts will be completed by (MONTH) 26, 2025. Nursing and social work will monitor the identified residents for potential adverse effects related to the stated deficient practice. The past 30 days of incident reports will be reviewed by the Director of Nursing or designee to determine the thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrences. Review will be completed by (MONTH) 26, 2025. If any areas are identified as being inconsistent with policy, further investigation will be completed at the time of review and, if required, incidents reported to the regulatory body per regulation and policy. All staff were educated on 2/12/25 - 2/13/25 on abuse reporting requirements and abuse reporting policy. **Element 3** Measures taken to ensure the practice does not reoccur: The abuse reporting/investigation policy was reviewed by the administrator, Director of Nursing, and nursing administration. The policy was revised. Policy updated to state all staff have the responsibility to immediately report any abuse/allegation of neglect, mistreatment, or misappropriation. Policy also updated to clarify the need to report all allegations within 2 hours to New York State Department of Health and, as appropriate, other regulatory entities. Education provided to social work, nursing supervisor, nurse managers, and administrator and all staff by a third-party consultant as part of a directed in-service plan. Education included but is not limited to the following: definitions of abuse, neglect, and mistreatment; reporting timeline; reporting obligations; investigation. The above education will be repeated yearly and is part of onboarding. All investigations will have a shift-to-shift handoff to the next senior leader (Supervisor, Director of Nursing, administrator, designee) to continue the investigation until all elements are complete to ensure the investigation is completed and closed. Any steps in the process missed by staff completing the investigation will receive immediate re-education by the administrator or designee. Review of the Centers for Medicare and Medicaid (CMS) Critical Element Pathway with the Registered Nurse Supervisory staff to ensure full understanding of the reporting requirements. Standard work instruction developed for use by the supervisor to ensure he/she has the tools needed to report all allegations/suspected/actual incidents of abuse per policy (immediately but no later than 2 hours) and to assist in the thorough investigation of all incidents. **Element 4** The facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Audits will be completed on 5 elders and 5 staff per week. Elders will be asked if they feel safe and if they have any concerns regarding staff or care. Audits will be completed by social work or designee. Staff will be audited on his/her knowledge of abuse reporting requirements. Staff audits will be done by Nurse Manager or designee on varying shifts. Any areas identified that require follow-up or education will be done immediately. Audits will be completed weekly for the first three months. Audits will be brought to the Quality Assurance Committee monthly. The committee will make recommendations based on audit results. The administrator or designee will update and maintain the Investigation Log at the time of each event to ensure that the facility appropriately responds and reports allegations of abuse, neglect, or mistreatment. 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. Conclusion 6. 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.