Failure to Monitor and Document Resident Status After Abuse Allegation
Penalty
Summary
The facility failed to ensure that the status of an alleged abuse allegation involving a resident was properly assessed and monitored. The resident, who had a history of stroke, mild cognitive impairment, and required significant assistance with activities of daily living, reported to a nurse practitioner that she had been inappropriately touched by a male staff member. Following this report, a Change in Condition (COC) evaluation was initiated, and facility policy required 72-hour monitoring with documentation for every shift. However, the progress notes only showed documentation on three occasions during the monitoring period, rather than for every shift as required. Interviews with facility staff confirmed that 72-hour monitoring should have been conducted and documented for every shift following a COC, especially in cases of alleged abuse. The Director of Nursing Covering Consultant and a Licensed Vocational Nurse both stated that this monitoring is necessary to observe any developments in the resident's condition and to ensure their safety and well-being. The facility's policy also specified that changes in a resident's condition or status must be recorded in the medical record. The lack of consistent monitoring and documentation represented a failure to follow professional standards and facility policy in response to the abuse allegation.
Plan Of Correction
a) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 1 was discharged to home on May 20, 2025. b) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents who experience a Change of Condition, to include an allegation of abuse, have the potential to be affected. On 05/23/2025, the MRD (Medical Records Director) reviewed the facilities current residents noted to have Change of Condition within the past 30 days to ensure that they were assessed timely and placed on 72-hour alert charting/documentation. The audit identified other residents noted to be affected. Current residents identified to be affected were reassessed on 05/30/2025 by RN. In addition, the nurse who completed the COC has also been identified and has received 1:1 formal education on the Policy & Procedure titled "Change in a Resident's Condition or Status". c) What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. On 05/27/2025, the Director of Nursing conducted an in-service with the facility's licensed nursing staff on the Policy & Procedure titled "Change in a Resident's Condition or Status". The Medical Records Department (MRD) will audit the medical records of residents identified to have a change in condition, including allegation of abuse, during each workday to ensure timeliness of documentation and that residents are also placed on alert charting/documentation. Non-compliance identified will immediately be brought to the attention of the Director of Nursing for further follow-up. d) How the facility plans to monitor its performance to make sure that solutions are sustained. The MRD will summarize the audit findings and present during the Quarterly QAPI meeting for further recommendation by the QA Steering Committee, until compliance has been achieved for three consecutive quarters. Compliance Date: 05/30/2025