Failure to Timely Report Resident-to-Resident Altercation and Suspected Abuse
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, and did not establish effective policies and procedures to investigate allegations of abuse for two residents. On the date of the incident, a resident with severe cognitive impairment and a history of aggression when his space was invaded, physically assaulted another resident who had moderate cognitive impairment and a history of wandering and behavioral symptoms. The altercation occurred when the wandering resident entered the other's room uninvited, resulting in the latter punching the former and knocking him to the ground. Staff intervened to separate the residents and conducted immediate assessments, but did not identify injuries at that time. Despite the altercation, facility staff did not report the incident to the administrator immediately after it occurred, as required by facility policy. The administrator, who also served as the abuse coordinator, was not made aware of the incident until much later and only learned of it through the survey process. Interviews revealed that staff were unclear about the reporting process and the identity of the abuse coordinator, with several staff members indicating they would report incidents up the chain of command rather than directly to the administrator as required. The facility's abuse policy required immediate reporting of suspected abuse, including resident-to-resident altercations, to the administrator/abuse coordinator and to state authorities, but this was not followed. Additionally, the facility failed to report the alleged abuse to Health and Human Services as mandated. Review of the Texas Unified Licensure Information Portal showed no self-report for the incident. The lack of timely reporting and failure to follow established procedures resulted in the identification of Immediate Jeopardy by surveyors. The deficiency was attributed to the breakdown in communication and lack of adherence to the facility's abuse reporting policy, as well as insufficient staff knowledge regarding the correct reporting process.
Removal Plan
- All residents were assessed by the nurse to ensure physical and emotional well-being.
- Administrator, Social Worker, Director of Nursing, or Designee will conduct team member and resident interviews to identify any concerns. If any are identified, nursing and social service will assess, notify the physician, local authorities, and the IDT, and will review the plan of care as indicated.
- Vice President of Operations conducted re-education to the Director of Nursing and Administrator regarding Abuse and Neglect, Identifying and Preventing, ensuring identified risk is on the plan of care and appropriate monitoring and supportive interventions are in place and an investigation is conducted.
- Vice President of Operations conducted a re-education of Abuse and Neglect reporting guideline to the Director of Nursing Services and Administrator.
- The Director of Nursing Services conducted education to the Assistant Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding Abuse and Neglect, Identifying and Preventing, ensuring identified risk is on the plan of care and appropriate monitoring and supportive interventions are in place and an investigation is conducted.
- Director of Nursing, Assistant Director of Nursing, Health Information Coordinator, and Memory Care Director conducted re-education to the team members regarding Abuse and Neglect, Identifying and Preventing, ensuring identified risk is on the plan of care and appropriate monitoring and supportive interventions are in place.
- Director of Nursing, Administrator, or Designee provided education to all team members regarding the process for monitoring, observing, and reporting all concerns involving resident to resident altercations or signs/symptoms of abuse, neglect, or exploitation by anyone, including family, visitors, or staff, immediately to their immediate supervisor and administrator/abuse coordinator to protect the safety and well-being of all residents and to ensure appropriate interventions are in place and the care plan/Kardex are adhered to as per facility’s expected practices.
- Director of Nursing or Designee to conduct re-education for all team members on Abuse and Neglect and reporting of Abuse and Neglect to all new team members and when using agency staff.
- Ad Hoc QAPI held with Administrator, Director of Nursing, and Medical Director to review abuse and neglect policy, reporting abuse and neglect, and review the plan of removal.
- Director of Nursing, Administrator, Social Worker, or Designee will conduct random daily rounds on various shifts to validate the safety and well-being of residents by conducting safe surveys.
- Director of Nursing or Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports, and the nursing 24 hr report during the morning clinical meeting to validate appropriate follow up and necessary interventions are in place. The Administrator will provide oversight by monitoring and validating this task to confirm completions. The regional nurse assigned to the community will review this system during her visits to validate completion.
- Findings will be reported to the QAPI committee during monthly meeting. The QAPI committee will determine compliance or identify a need for additional training.