Failure to Report Alleged Abuse and Mistreatment to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and mistreatment to the State Agency as required, involving two residents. Specifically, an incident occurred in which one resident was alleged to have touched another resident inappropriately during the midnight shift, and there were additional concerns that the same resident was seeking out other women in the facility for sexual activity. Despite these serious allegations, the facility did not report the incidents to the State Agency in accordance with federal requirements. The medical record review and interviews confirmed that staff were aware of the events, including a commotion in the room, visible intoxication, and the presence of alcohol, but failed to follow established reporting procedures. The resident involved had a history of behavioral issues, including agitation, verbal and physical threats, and substance abuse, as documented in multiple progress notes. These notes detailed repeated incidents of aggression toward other residents and staff, including attempts to physically confront or threaten others, use of profanities, and disruptive behavior. Despite this documented pattern and the specific incident of alleged abuse, the facility did not ensure timely reporting to the appropriate authorities as required by regulation.
Plan Of Correction
Element 1: Resident R907's allegation of abuse has been reported to the State of Michigan. Completed by the Abuse Coordinator on 5/1/2025. Resident R907 has been reviewed for any negative outcomes related to the alleged violation by Social Services / Designee. Care plan has been reviewed and updated as needed by Social Services. Completed by 5/8/2025. Resident R901 no longer resides in the facility. Element 2: All current residents in the facility have the potential to be affected. The facility Administrator / Designee has reviewed all grievance forms for the last 30 days for any reportable incidents. Any reportable incidents were reported. This was completed by the administrator on 5/6/2025. Root Cause Analysis: Facility failed to follow the abuse, neglect, and exploitation policy to report an allegation of abuse within 2 hours of notification. Element 3: The Abuse, Neglect, and Exploitation policy was reviewed by the QAPI committee and deemed appropriate on 5/2/2025. The facility administrator was re-educated on the reporting guidelines of abuse by the Regional Director of Operations on 5/7/2025. The Director of Nursing / Designee has re-educated all current employees on the Abuse, Neglect, and Exploitation policy by 5/19/2025. Any current employee who is not re-educated by 5/19/2025 will be re-educated prior to their next scheduled shift. All allegations of abuse and grievance forms are to be reviewed daily, Monday through Friday, in morning meetings and are to be reported by the facility. Element 4: The Administrator will audit up to 5 grievance forms weekly to ensure there are no reportable incidents. Audits will be weekly x4 weeks then monthly thereafter until substantial compliance is achieved. The results of the audits will be reviewed by the QAPI committee for 3 months or until substantial compliance is met. The facility administrator is responsible for compliance.