Failure to Ensure Timely Reporting and Implementation of Policies Following Resident Incident
Penalty
Summary
A deficiency occurred when facility staff failed to implement policies and procedures regarding an incident between two residents. A staff member entered the room of two residents, observed one resident engaged in an act with the other, and then proceeded to finish her task of collecting hangers before leaving the room. Instead of immediately reporting the incident to a supervisor or nurse as required, the staff member went on her lunch break for approximately 30 minutes. Upon returning from lunch, she reported the incident to a co-worker, who then reported it to the appropriate personnel. The delay in reporting was confirmed during interviews, with the staff member admitting she was aware of the need to report immediately but did not do so out of fear and uncertainty about her supervisor's availability. The residents involved had relevant medical histories and cognitive assessments documented in their records. One resident had a BIMS score indicating impaired cognitive function, and the other also had a care plan noting a history of certain behaviors and interventions. The facility's investigation and interviews with staff revealed that both residents were questioned about the incident, with one denying and the other confirming what was observed. Staff interviews further indicated confusion and inconsistency regarding the residents' capacity to consent to the observed actions, particularly in relation to their BIMS scores. The facility's administration was found to have failed in ensuring that staff followed established protocols for reporting and responding to such incidents. The administrator and department heads were not immediately aware of the delay in reporting, and the staff member's written statement did not accurately reflect the sequence of events. The deficiency was identified as placing all residents at risk due to the failure to ensure prompt reporting and intervention, as required by facility policy and regulatory standards.
Plan Of Correction
F835 Administration 1. Corrective Action: - Effective May 13, 2025, the Administrator of record is no longer employed at the facility. The new Administrator of record began on NJ Ex Order 26.4(b)(1). - On May 15, 2025, the corporate Administrator oriented the new Administrator of record to her job description, previous and current plans of corrections, and statement of deficiencies. 2. Identification of other areas having the potential to be affected due to the nature of this deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put in Place: - The corporate Administrator and/or designees will meet weekly with the new Administrator of record for 4 weeks and then monthly for 6 months to assure that processes and procedures are compliant with company policy. 4. How Will These Actions Be Measured: - The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. - Based on the results of these audits, a decision will be made regarding the need for continued submission of reporting. - The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Removal Plan
- Educated the Administrator on their job description.
- Educated the department heads on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.
- Educated the governing body on their roles and responsibilities to ensure the facility administration maintains the highest practicable, physical, mental, and psychosocial well-being of each resident.