Failure to Immediately Report Staff-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with a history of traumatic brain injury and behavioral issues exhibited escalating combative and aggressive behaviors. 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 aggression. A certified nurse aide witnessed this staff-to-resident abuse. Despite witnessing the incident, the certified nurse aide did not immediately report the abuse to administrative staff as required by facility policy. Instead, the incident was reported the following day when the aide returned for her next shift. This delay in reporting meant that the facility administrator was not promptly informed of the abuse, which is a violation of the facility's abuse prevention policy that mandates immediate reporting of all alleged or suspected abuse. The failure to ensure immediate reporting of the abuse placed the resident in immediate jeopardy. The facility's own documentation and staff interviews confirmed that the incident was not reported in a timely manner, and that the required notification to administrative staff was delayed until the next day. This lapse in procedure directly contributed to the deficiency cited by surveyors.
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.