Failure to Report Abuse Allegation and Maintain Sufficient Staffing
Penalty
Summary
On the night in question, two residents with histories of alcohol dependence and cognitive impairment were found intoxicated together in one resident's room. One resident, who had severely impaired cognition and a BIMS score of six, reported being prevented from leaving the room and being inappropriately touched by the other resident. Staff responded to the resident's calls for help and found both individuals in the same bed, with evidence of alcohol consumption present. The incident was reported by a CNA to a nurse, and a quality assurance form was completed, but the administrator was not informed until days later, contrary to facility policy requiring immediate reporting of abuse allegations. The facility was experiencing a staffing shortage during the shift when the incident occurred, with only four nurses present instead of the required six. Staff reported being unable to provide adequate supervision for residents, particularly those with behavioral issues and high fall risks. As a result, multiple residents received their medications late, and supervision was insufficient to prevent or promptly address incidents such as the one involving the two intoxicated residents. Staff also indicated that the resident accused of inappropriate touching had a history of problematic behavior, including drinking and inappropriate interactions with other residents. Facility policies reviewed during the investigation required immediate reporting of abuse allegations and sufficient staffing to ensure resident safety and well-being. However, the failure to promptly notify the administrator of the abuse allegation and the inability to maintain required staffing levels led to delayed medication administration and inadequate supervision. These actions and inactions directly contributed to the deficiencies identified in the report.
Plan Of Correction
Weekend staffing will be reviewed on Friday in morning stand-up meeting. Any concerns will be addressed. Element 4: The Administrator will conduct a daily staffing meeting, Monday through Friday, to ensure that nurse staffing is sufficient to meet the residents' needs. Staffing meetings will be held daily, Monday through Friday, for four weeks, then weekly 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.