Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report suspected abuse within the required two-hour timeframe and did not submit a completed investigation for an allegation of abuse within five working days, as required by regulation. Two residents experienced abuse by a CNA, with one incident involving physical abuse resulting in a nosebleed and verbal abuse, and another incident involving verbal threats. Both incidents were witnessed by other CNAs, but neither was reported immediately due to fear of retaliation from staff. The abuse was only reported ten days after the initial incident, when anonymous letters were left for the Administrator. The facility's policy required any employee who witnesses or has knowledge of abuse, neglect, exploitation, or mistreatment to report the information within two hours to the Administrator and other officials in accordance with state law. Despite this, the CNAs who witnessed the abuse did not report it promptly, leaving residents at risk for continued abuse. The Administrator became aware of the incidents only after receiving anonymous letters, at which point the accused CNA was suspended and subsequently terminated. Additionally, the facility failed to submit a final investigation report to the State Agency within five working days for a separate allegation of verbal abuse involving another resident. The Administrator and DON acknowledged that the final report was not sent due to the DON's illness and oversight, despite being aware of the requirement. This failure to report and investigate in a timely manner was determined to be Immediate Jeopardy and Substandard Quality of Care.
Removal Plan
- Quality Assurance (QAPI) Committee met to review, develop, and implement the facility policy on abuse and neglect with an emphasis on reporting abuse and neglect and to determine the root cause. The root cause was determined to be that employees were afraid of retaliation from other employees. Attendees included the Executive Director, MDS nurse, Medical Records, Regional Director of Clinical Services, Assistant Director of Nursing, Medical Director, Social Services, Staff Development/Infection Preventionist nurse, Activities Director, Human Resources, Housekeeping, Dietary Manager, Therapy director, Unit Managers, and the Admission Coordinator. No changes were made to the policy and procedure. The areas discussed were the re-education of staff members on the abuse and neglect policy with an emphasis on reporting requirements and that failure to do so is a crime.
- Body audits were completed on Resident #1 and Resident #2 by the Staff Development nurse and a licensed nurse. No signs of physical abuse were identified.
- Interviews were conducted by Social Services Director with alert and oriented residents on side 2. No residents voiced complaints of abuse.
- 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 met to review 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. No residents were identified.
- The Executive Director was educated on the abuse policy by the Regional Director of Clinical Services and timely reporting of abuse within 2 hours 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 (census) using the Risk Management Quality Improvement Questionnaire to determine if any residents had been abused or witnessed abuse. There were no residents that voiced any complaints of 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 and 100% was completed.
- 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 and that failure to do so is a crime.
- 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.