Failure to Prevent and Investigate Resident and Staff Incidents
Penalty
Summary
The facility failed to ensure resident safety and well-being by not preventing unauthorized individuals from entering the facility and not preventing incidents involving residents. There was a lack of safety measures to prevent the use of prohibited substances by residents, and the facility did not conduct thorough investigations into incidents involving staff-to-resident and resident-to-resident interactions. Specifically, the administrative staff did not investigate an incident involving a resident who was found in distress and later transferred to the hospital, despite the resident's history of substance use and suspicious behavior observed by staff. The staff did not report or investigate the incident as required, and there was no notification to the Department of Health or law enforcement regarding the event. Additionally, the facility failed to conduct a thorough investigation into an allegation involving a staff member and a resident. When a resident reported observing an LPN in a resident's room under suspicious circumstances, the administrative staff did not interview all relevant residents or staff members, nor did they collect statements as per facility policy. The investigation was limited and did not follow the established procedures for handling such allegations, as acknowledged by the staff during interviews with surveyors. The facility's job descriptions for the Administrator and Director of Nursing outlined responsibilities for maintaining safety standards and conducting thorough investigations, but these were not followed in practice. The lack of proper investigation and failure to implement safety measures placed all residents at risk and resulted in a finding of Immediate Jeopardy by surveyors.
Plan Of Correction
F835 Administration ELEMENT ONE: CORRECTIVE ACTION: The abuse and illicit drug policies were reviewed and updated. The U.S. FOIA (b) (6) and U.S. FOIA (b) (6) received re-education by the corporate officer on job description and abuse and illicit drug policies, which includes reporting to the New Jersey Department of Health and police on 5/9/25. The Licensed Nursing Home Administrator and Director of Nursing re-educated staff on abuse and illicit drug policies, which includes reporting to the New Jersey Department of Health and police on 5/9/25. The Social Worker met with residents with a history of NJ Ex Order 26.4(b)(1) and/or NU EXOTORRADX to educate on the availability of NJ Ex Order 26.4(b)(1) programs, the medical risks of NJ Ex Order 26.4(b)(1) NJ Ex Order 20 involvement, possible discharge from the facility, and revoking of facility leave privileges on 5/9/25. Nursing staff was re-educated on signs of NU EXOrder 26.4DX and policies to follow in cases of suspected ExOrder 254(DX(1)) and the availability of NU Ex Order 26.4(b)(1) programs for residents on 5/9/25. The Director of Nursing / designee re-educated staff on signs of J Ex Order 25.4(D)(1) and policies to follow in cases of NJ Ex Order 26.4b1. The Director of Nursing re-investigated the incidents involving Residents #3, #6, #8, and #15. Care plans of residents cited in the 2567 were reviewed and/or updated by the interdisciplinary team. Incidents and accidents occurring from January through May were audited to ensure there were no identified, unresolved NJ Ex Order 26.4(b)(1) and/or NJ Ex Order 26.4(b)(1). ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS: All residents have the potential to be affected by this practice. ELEMENT THREE: SYSTEMIC CHANGES: Policy signage was posted at the entrance stating that [R] and [R] are not allowed in the home on 5/9/25. The Social Worker meets with new residents who have a history of [R] and/or [R] to discuss policy and options for treatment of [R]. [R] and violations of [R] policy are discussed at weekday clinical meetings and reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. ELEMENT FOUR: QUALITY ASSURANCE: Root cause analysis was conducted and a QAPI performance improvement project team formed to address clinical concerns. Abuse allegations and violations of illicit drug abuse policy are discussed at weekday clinical meetings, and all concerns are 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 meeting for 3 months. Based on the results of these audits, a decision will be made regarding review and further direction as appropriate. DATE OF COMPLIANCE: June 9, 2025
Removal Plan
- The Corporate Officer re-educated staff on their job descriptions and the facility's policies on conducting a thorough investigation and the facility's elimination efforts.
- Signage was posted in the front of the building that no alcohol or drugs were allowed in the facility.
- The designee educated all the facility staff on elimination of use in the facility and to report any use to the Department of Health.
- Incidents and accidents were audited to ensure there were no additional unresolved issues identified.
- An audit process was implemented during the clinical meeting to assess concerns and ensure these were addressed per the facility policy.