Failure to Conduct Thorough Abuse Investigations and Follow Facility Policy
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse, neglect, or mistreatment as required by federal regulations and its own policies. In one instance, a resident was observed to have experienced an incident involving another resident, but the facility did not conduct a comprehensive investigation beyond speaking with the two residents involved. There was no documented follow-up, no collection of witness statements, and no further inquiry outside of a grievance filed for the affected resident. The facility's policy, which mandates timely and thorough investigation including obtaining written statements from staff and interviewing witnesses, was not followed. In another case, a resident reported witnessing an incident involving an LPN and another resident. The LPN was suspended immediately after the report, but the investigation was limited to interviews with the reporting resident, the accused LPN, and two other staff members. The facility did not interview or assess other residents who were under the care of the LPN, nor did it obtain statements from other staff who worked on the unit during the time frame in question. The responsible staff member acknowledged that a more thorough investigation, including interviews with all potentially affected residents and staff, was not conducted due to uncertainty about the timing of the alleged incident. These failures to follow investigative protocols and facility policy resulted in the facility not ensuring the protection of residents during the investigation process. The lack of comprehensive investigation and documentation placed multiple residents at risk, as the facility did not take all necessary steps to determine the extent of potential abuse or mistreatment. The surveyor found that these deficiencies affected several residents, some of whom had cognitive impairments or other medical conditions, and that the facility did not implement its abuse prevention and investigation policy as required.
Plan Of Correction
F610 *Investigate/Prevent/Correct Alleged Violation 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 NJ Exec Order. The Licensed Nursing Home Administrator and Director of Nursing re-educated the U.S. FOIA (b) (6) and all nursing staff on the abuse policy to include reporting abuse and conducting a thorough investigation on NJ Exec Order 25 and NJ Exec Order 2. The resident-to-resident involving Resident #8 and Resident #15 on NJ Exec Order 26.401 was reinvestigated by the U.S. FOIA (b) (6) on NJ Exec Order. The NJ Exec Order 26.4(b)(1) involving LPN #1 and Resident #3 on 4/25/25 was reinvestigated by the U.S. FOIA (b) (6) to include interviews with residents on LPN #1's work assignment and witness statements from staff on 5/8/25. Incidents and accidents occurring from January 2025 through May 2025 were audited to ensure there were no identified, unresolved allegations of abuse and neglect. 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 are educated about abuse policy at Resident Council meetings. 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, 202
Removal Plan
- All facility staff were educated on the facility's abuse-prevention policy, recognition of and types of abuse, reporting urgency, and reporting to regulatory agencies.
- Audited all incidents and accidents to assure there were no additional unresolved incidents identified.
- Implemented an auditing process to assess potential incidents and ensure concerns are addressed through the policy.
- Auditing of all incidents/accidents will occur Monday through Friday, with weekend incidents/accidents included in the Monday audit.
- Residents that were on LPN #1's schedule were interviewed and assessed for any complaints of inappropriate behaviors requested or witnessed by LPN #1.
- Educated the social workers and administrative nursing staff on the facility's policy on reporting of abuse and conducting a thorough investigation.
- Conducted an investigation into incidents and accidents.
- Implemented an auditing process to assess potential incidents and ensure concerns are addressed through the policy.
- Auditing of all incidents/accidents will occur Monday through Friday, with weekend incidents/accidents included in the Monday audit.