Failure to Report Alleged Neglect to Appropriate Agencies
Penalty
Summary
A deficiency was identified when the facility failed to ensure that an allegation of neglect involving a resident was reported to the appropriate agencies as required by federal regulations. The incident involved a resident who was found by a CNA to be covered in feces from the waist down, with some of the feces dried on, indicating the resident had been in that condition for an extended period. The resident reported that he had been asking to be changed all morning and had not been attended to until the afternoon shift began. The CNA who discovered the situation documented the incident and reported it to the nurse and unit manager, and a grievance report was completed. Review of the facility's documentation revealed that a "Teachable Moment" form was created regarding the incident, but it was not properly signed or presented, and the Human Resource Director was unaware of its existence. The section of the grievance report that indicated whether the incident was reportable to the state agency was left unmarked. The facility administrator confirmed that the incident was not reported to the state agency or other required officials, despite acknowledging that the care provided was not appropriate and had the potential to be considered neglect. The facility's policy requires immediate reporting of allegations of neglect to the administrator and appropriate agencies, but this process was not followed in this case. The administrator stated that the standard procedure would involve notifying the clinical team, risk manager, and submitting the incident through the appropriate reporting systems, but confirmed that these steps were not taken for this incident.
Plan Of Correction
1. Resident #9 was assessed by nursing and social services and no adverse effects were noted. Resident remains in the center. Staff B was terminated. Resident #9 interviewed by NHA and resident stated that he felt safe in the center and had no additional concerns at the time of the interview. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and education scenarios provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.