Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and timely report criminal allegations of abuse and neglect involving an LPN to local law enforcement and required agencies. Multiple staff members, including housekeepers and nurse aides, reported concerns that the LPN was administering medications such as melatonin and Tylenol to residents without proper orders, resulting in residents appearing sedated, lethargic, and unable to eat or remain awake during the day. Staff also noted an increase in resident deaths on the memory impaired unit during shifts when the LPN was working. These concerns were documented in witness statements and interviews, with specific observations of residents' abnormal behavior and changes in condition, such as hypothermia and excessive sleepiness. Despite these serious allegations and observations, the facility did not promptly initiate an investigation or report the incidents to the Area Agency on Aging, the Department of Health, or local law enforcement as required by state law and facility policy. The Director of Nursing and Nursing Home Administrator were made aware of the allegations but delayed reporting for ten days, only notifying authorities after being prompted during the survey process. The DON dismissed the initial reports as hearsay and gossip, contributing to the delay in addressing the allegations. The failure to act on staff reports and to follow mandated reporting procedures resulted in an immediate jeopardy situation, as the facility did not ensure the protection of residents from potential abuse or neglect. The deficiency was identified through review of facility documentation, staff interviews, and examination of resident records, which confirmed that the facility did not comply with legal and policy requirements for timely reporting and investigation of suspected abuse and neglect.
Removal Plan
- Review current residents' medical records for signs of abuse/neglect by the DON and/or designee. Interview all interviewable residents for any signs and/or symptoms of abuse and/or neglect. If any allegations of abuse/neglect are found, follow abuse policy, and begin investigation and reporting immediately.
- Interview staff for review of abuse/neglect allegations that have not been reported to the DON and/or designee. If any allegations are identified, begin investigation and reporting immediately.
- Update review of Electronic event report for neglect allegation by the DON/designee to accurately reflect concern for Nurse giving Tylenol and Melatonin to all residents on the memory unit whether there is an order or not thus causing potential harm.
- Review Abuse/Neglect Policy, Incidents and Accidents Policy, and reporting criteria by NHA and/or designee 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 prior to their next shift worked.
- Audit all residents who have had an allegation of abuse/neglect in the last 30 days by the DON and/or designee to ensure that it was reported appropriately and timely.
- Review all audits and policy changes related to IJ 609 at an Ad hoc Quality meeting.