Failure to Protect Resident from Abuse and Incomplete Investigation
Penalty
Summary
The facility failed to protect a resident from abuse and did not follow its own policy titled "Abuse, Resident Behavior and Facility Practice." An incident occurred in which a resident was observed to have injuries of unknown origin after sharing a room with another resident who had a documented history of behavioral issues. The staff did not immediately separate the residents or implement the abuse policy as required. There was no documentation in the medical record or progress notes to indicate that the care plan for the resident with behavioral issues was followed at the time of the incident. Additionally, the facility did not conduct a thorough investigation into the incident. There was no record of a Facility Reportable Event (FRE) being filed with the New Jersey Department of Health, and no investigation was completed for the event. Staff interviews revealed that key steps were missed, such as interviewing the roommate and other potential witnesses, and there was a lack of follow-up outside of a grievance form. The supervisor and LPN involved did not speak with all relevant parties or document their actions in accordance with facility policy. The failure to follow established procedures and policies resulted in the residents not being protected from potential abuse. The lack of immediate action, incomplete documentation, and insufficient investigation placed the affected resident and others at risk. The facility's own staff acknowledged that the abuse policy was not followed and that necessary steps, such as interviewing all involved individuals, were omitted.
Plan Of Correction
F 000 F600 *Free from Abuse and Neglect ELEMENT ONE: CORRECTIVE ACTION: The U.S. FOIA (b)(6) received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for NJ Exec Order 26.4b1 and the requirements to report these incidents to the DOH/police/LTCO on 5/9/25. Resident #15 was evaluated for signs of NJ Exec Order 26.4b1 and none were noted. The LPN involved in the incident involving Resident #8 and Resident #15 no longer works at the building. The caring for Residents #8 and #15 on NJ Ex Order 26.4(b)(1) was re-educated on the abuse policy on 5/9/25. The care plans of Residents #8 and #15 were reviewed and updated on 5/9/25. The U.S. FOIA (b) (6) met with Resident #15 to support and offer a room change on NJ Exec Order 26.4b1. Resident #8 and Resident #15's incident of der 26.4b1 was reinvestigated by the U.S. FOIA (b) (6) on 5/9/25. The Director of Nursing / designee re-educated all nursing staff about the abuse policy on 5/9/25. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect on 5/12/25. ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. All residents were educated regarding the abuse policy at the resident council meeting held on 5/7/25. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Allegations of abuse are discussed at weekday clinical meetings and all concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 2025 audits of the daily meeting and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for 3 months. Based on findings, a decision will be made regarding review and further directives. DATE OF COMPLIANCE: June 9, 2025 F 600 F 600
Removal Plan
- The facility implemented a corrective action plan to remediate the deficient practice.
- All facility staff were educated on the facility's policy abuse prevention, recognition of and types of abuse, reporting urgency and reporting to the regulatory agencies.
- The facility audited all incidents and accidents to assure there were no additional unresolved of identified.
- The facility implemented an auditing process to assess potential and ensure concerns are addressed through the policy.
- Auditing of all accidents will occur Monday through Friday, with weekend incidents included in the Monday audit.
- The residents that were on LPN #1's schedule were interviewed and assessed for any complaints of NJ Ex Order 26.4(b)(1) requested or witnessed by LPN #1.
- The SMRT and the US FOIA (D) educated the social workers (SW) and administrative nursing staff on the facility's policy on reporting of Exous and conducting a thorough investigation.
- The U.S. FOIA (b)(6) conducted an investigation into incidents and accidents from NJ Ex Order 26.4(b)(1).
- An audit was implemented daily at morning clinical meeting on all accidents and incidents to determine if conducted investigations were completed correctly.