Failure to Implement Abuse Policy and Immediate Reporting
Penalty
Summary
The facility failed to implement its abuse policy, resulting in two incidents of abuse involving two residents. In the first incident, a resident with Parkinson's Disease and Dementia, who had a moderately impaired cognitive status, was physically abused by a CNA during care. The CNA responded to the resident's combative behavior by grabbing and twisting the resident's nose, causing it to bleed, and made a derogatory comment. This act was witnessed by another CNA, who did not immediately report the incident or intervene effectively, despite being aware of the facility's abuse policy and having received training on the obligation to report abuse. In the second incident, another resident with severe cognitive impairment and dependent on staff for toileting hygiene was verbally abused by the same CNA. The CNA threatened the resident with physical harm if the resident soiled the bed again. This was overheard by a different CNA, who confronted the abusive CNA but also failed to report the incident at the time. Both witnessing CNAs later admitted they did not report the abuse immediately due to fear of retaliation from other staff members, even though they were aware of the reporting requirements outlined in the facility's policy. The facility's policy required all employees to report any witnessed or known abuse within two hours to the Administrator and other officials as per state law. However, the incidents were not reported until anonymous letters were received by the Administrator, leading to a delayed response. The failure of staff to intervene and promptly report the abuse placed the affected residents and others at risk for further abuse and constituted a violation of residents' rights to be free from abuse.
Removal Plan
- Quality Assurance (QAPI) Committee reviewed, developed, and implemented the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2.
- The physician and the Resident Representatives of Resident #1 and Resident #2 were notified.
- Education was started by the Staff Development Nurse.
- Quality Assurance Performance Improvement Committee reviewed the physical and verbal abuse.
- Social Services completed a psychosocial follow up with Resident #1 and Resident #2.
- 100% body audits were performed on all facility residents by the unit manager RN and the Minimum Data Set nurses to ensure that residents did not have physical signs of abuse.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse to the state agency, attorney general and the abuse and neglect policy.
- The Social Services Director and the Admissions Coordinator interviewed all alert and oriented residents using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse.
- The Staff Development nurse started education with licensed nurses, CNAs and non-direct care staff on the abuse and neglect policy and procedure with an emphasis on reporting requirements.
- All facility staff members were interviewed by the Executive Director, Human Resources, and Assistant Director of Nursing by phone to ask if they ever witnessed any employee abuse a resident and explained the process of what to do if they ever witness abuse or neglect, with an emphasis on reporting requirements.
- CNA #2 received one on one education on the abuse policy and the reporting requirements with an emphasis placed on the fact of not reporting being a crime.
- New hires will be educated during orientation.