Staff-to-Resident Abuse and Delayed Reporting of Incident
Penalty
Summary
A resident with severe cognitive impairment, traumatic brain injury, and a history of aggressive behaviors exhibited escalating agitation and aggression, including yelling, cursing, and physical aggression toward staff. During an incident, the resident grabbed a licensed nurse's genitals and used obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse also reported using a restraint technique involving grabbing the resident around the neck to prevent further aggressive behaviors. This interaction was witnessed by a certified nurse aide, who did not report the abuse to administrative staff until the following day. The resident's care plan instructed staff to intervene calmly before agitation escalated, to guide the resident away from distress, and to reapproach if the resident became aggressive. Staff were also directed to expect frequent use of profanity and to encourage appropriate language. Despite these care plan instructions, the nurse's actions during the incident included physical and verbal abuse, as well as the use of an unauthorized restraint technique. The nurse had not received formal dementia training since being hired, although he had attended a staff meeting that included behavioral management topics. The facility's policy required immediate reporting of any witnessed or alleged abuse, but the certified nurse aide who witnessed the event delayed reporting until her next shift. The facility's investigation confirmed the incident and noted the delay in reporting. The nurse involved was suspended and later terminated. The failure to protect the resident from staff-to-resident abuse and to ensure timely reporting of abuse constituted a deficiency and resulted in immediate jeopardy for the resident.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.