Delayed Reporting of Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect within the required two-hour timeframe for a resident. The incident involved a Certified Nursing Assistant (CNA) and a resident, where the resident accused the CNA of grabbing her arm and causing bruises. The facility's policy mandates immediate reporting of such allegations, especially if they result in serious bodily injury, but the report was delayed. The incident began when the resident requested assistance from the CNA, who was attending to another resident at the time. Upon returning to assist the resident, the CNA reported that the resident became combative, grabbing the CNA's shirt and hitting her. The CNA called for help, and other staff members responded. The resident later alleged that the CNA had grabbed her arm tightly, causing bruises. The incident was not reported to the Nursing Home Administrator until several hours later, despite staff being aware of the situation earlier in the day. Interviews with staff revealed that the CNA involved was suspended during the investigation, and the Director of Nursing was informed of the incident later in the afternoon. The delay in reporting was attributed to a lack of immediate investigation and communication among staff. The resident's care plan noted self-neglect behaviors and a history of refusing care, which may have contributed to the incident. However, the facility's failure to adhere to its reporting policy resulted in a deficiency finding.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect, and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.