Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to report multiple alleged violations involving abuse, neglect, or mistreatment to the New Jersey Department of Health (NJDOH) and other required authorities within the regulatory timeframes. In one instance, a resident was observed with injuries of unknown origin, and the facility did not provide documentation that a Facility Reportable Event (FRE) was completed or submitted to the NJDOH. The resident was unable to recall how the injury occurred, and the staff member interviewed stated they did not consider the incident reportable due to the resident's lack of recollection, despite acknowledging that such events should be reported. In another case, a resident reported to an LPN that they intended to report the LPN for an incident involving another resident. The LPN was suspended pending investigation, but the FRE did not indicate whether the required notification to the NJDOH was made. The staff member interviewed admitted to not notifying the appropriate authorities because they felt the allegation was unsubstantiated, contrary to regulatory requirements. A third incident involved a resident reporting to staff and the Ombudsman that an LPN had spoken to them inappropriately. The event was eventually reported to the NJDOH, but not within the required timeframe. The staff member confirmed that the report was delayed and acknowledged that it should have been made sooner. The facility's own policy requires timely reporting of all allegations of abuse, neglect, or mistreatment to regulatory agencies, but this was not followed in these cases.
Plan Of Correction
F609 Reporting of Alleged Violations ELEMENT 1 The U.S. FOIA (b) (6) and [R] received re-education by the corporate officer on job description and facilities policies on conducting a thorough investigation for [R] and the requirements to report these incidents to the DOH/police/LTCO on 5/9/25. The Director of Nursing / designee re-educated all leadership staff about the abuse policy to include abuse prevention, recognition of and types of abuse, reporting urgency, and reporting to the regulatory agencies. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect. The New Jersey Department of Health, police, and ombudsman were notified regarding the 10/12/24 incident between Residents #8 and #15. The police were notified regarding the 4/25/25 incident between LPN #1 and Resident #3. ELEMENT 2: All residents have the potential to be affected by this practice. ELEMENT 3: 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. ELEMENT 4: 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 x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025