Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
A facility failed to report an allegation of neglect to the appropriate agencies as required by state and federal regulations. The incident involved a resident who was found covered in feces, with evidence indicating he had been left in that condition for several hours. The resident, who was totally dependent on staff for toileting, reported that he had been asking to be changed all morning and had not received assistance until the afternoon shift began. The staff member assigned to the resident during the morning shift had already left the building before the afternoon aide discovered the situation. Documentation in the resident's clinical chart and care plan confirmed his dependence on staff for activities of daily living, including toileting. A "Teachable Moment" form was found in the personnel file of the CNA assigned to the resident, describing the incident and noting that the resident had been left in feces for an extended period. However, the form was unsigned, and the Human Resource Director was unaware of its origin. The afternoon CNA who discovered the resident reported the incident to the nurse and unit manager, and also submitted a written statement and grievance report detailing the neglect. Despite these reports and documentation, the incident was not reported to the state agency as required. The Nursing Home Administrator acknowledged that the care provided was not appropriate and had the potential to be considered neglect, but confirmed that the incident was not reported through the required channels. The process for reporting such allegations was described, but in this case, it was not followed.
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 any other residents or were abused at any time. Skin assessments were completed for residents with 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 scenarios. Education 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. Mistreated, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated coordinator. Once an allegation of mistreatment is reported, the Executive Director, as the coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred. A review of Resident #9's clinical chart documented an admission of his diagnosis list included but not limited to Type 2 diabetes. A review of a dated document showed a score of 13, with a comment "Intact response." A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance and is at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting. A review of Staff B, Certified Nursing Assistant's... 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.