Failure to Educate Staff and Timely Respond to Abuse/Neglect Allegations
Penalty
Summary
The facility failed to ensure that all nursing staff were educated on abuse and neglect prior to working in the facility and annually, as required by policy. Specifically, one LPN did not receive abuse/neglect education before starting work, and two other nursing staff members did not receive annual abuse/neglect education. This lack of training was confirmed through review of employee files, facility documents, and staff interviews. Additionally, the facility did not complete required onboarding documentation for agency staff prior to their start date. Multiple staff members reported concerns regarding the actions of an LPN working on the memory impaired unit, including allegations that the LPN administered medications such as melatonin and Tylenol to all residents regardless of physician orders. Staff observed that residents appeared more sedated, lethargic, and unable to eat or wake up during the day when this LPN was on duty. There were also concerns raised about an increase in resident deaths and changes in resident conditions, such as hypothermia, that were not properly reported or followed up by nursing staff. Despite these reports, the facility failed to identify, report, and investigate these allegations of abuse and neglect in a timely manner. The facility allowed the LPN who was the subject of abuse/neglect allegations to continue working after the concerns were reported, without immediate suspension or implementation of a supervision plan. The Director of Nursing and Nursing Home Administrator confirmed that they did not initiate an investigation or report the allegations to appropriate agencies promptly. Witness statements and interviews revealed that staff were aware of the allegations but did not report them immediately, and the facility did not obtain witness statements until several days after being notified of the concerns.
Removal Plan
- Review current medical records for any signs of abuse/neglect and interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any is found, follow abuse policy and begin investigation and reporting immediately.
- Interview all staff for allegations of abuse/neglect that have not been reported. If any are identified, begin investigations and reporting immediately.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on immediate reporting of any allegation/neglect.
- Provide education by the Chief Nursing Officer to the Director of Nursing and Nursing Home Administrator on the immediate suspension of an employee with an allegation of abuse/neglect.
- Provide education by the DON/Designee to Licensed Nursing Staff both in house and agency on the appropriate medication administration and following Physician's orders.
- Audit each resident's Medication Administration Record (MAR) and Treatment medication Record (TAR) to ensure medications and treatments have been administered/given as ordered.
- Review the Abuse/Neglect Policy and update if needed.
- Educate all house staff and agency staff on the abuse/neglect policy and reporting abuse by the DON and/or designee.
- Review all audits and policy changes related to immediate jeopardy at an ad hoc Quality meeting.
- Interview all staff for instances of abuse/neglect that were not reported. Report and investigate any incidents timely.
- Require all licensed nursing staff, not educated, to verify education on physician orders and MAR/TARs.