Failure to Protect Residents from Abuse and Timely Reporting of Incidents
Penalty
Summary
The facility failed to ensure residents were protected from abuse, neglect, misappropriation of property, and exploitation, as evidenced by multiple incidents involving resident-to-resident altercations. Several residents with cognitive impairments and behavioral health diagnoses were involved in physical altercations, resulting in injuries such as a non-displaced nose fracture and a lumbar vertebral fracture. Documentation revealed that one resident was hit in the back by another, another was punched in the face, and another was pushed to the ground, all occurring within a short time frame. Additionally, a resident was grabbed, pulled, and scratched by another resident, leaving visible marks. The facility's records and staff interviews indicated that there were lapses in timely reporting and investigation of these incidents. The Administrator was unaware of the requirement to report abuse within two hours and did not report certain altercations to the state agency, believing that no injury had occurred. There was also a lack of comprehensive care planning for some residents, and staff did not consistently notify supervisory personnel of altercations as required. In some cases, the facility did not complete or document required assessments and care plans for residents involved in these incidents. Interviews with staff and review of documentation showed that staff responses to altercations varied, with some staff intervening and notifying supervisors, while others did not follow established protocols. The facility's failure to protect residents from abuse and neglect, as well as the lack of timely and appropriate reporting and investigation, led to the identification of Immediate Jeopardy. The deficiencies placed residents at risk for continued abuse and negative psychosocial outcomes.
Removal Plan
- Residents were separated from each other and monitored until no further aggressive behaviors were demonstrated.
- Resident #5, #2, and #1 were referred to behavioral unit for inpatient treatment.
- Resident #2 was sent to ER for evaluation and treatment.
- Prior to being admitted to inpatient behavior hospital, #2 & #1 were sent to ER for evaluation and treatment.
- Regional Director of Operations educated Administrator and DON on types of abuse and policy to keep all residents free from abuse and neglect.
- All staff will be re-educated on the facility's Abuse/Neglect Policy by DON, Administrator, department supervisors and nurse manager including identification, prevention, and mandatory reporting requirements.
- In-services will continue; all staff must be in-serviced before starting their shift.
- Documentation of re-education and staff signatures will be completed; all staff will be in-serviced before starting their shift.
- Staff were instructed to immediately intervene and report any signs of resident-to-resident aggression or abuse to the Administrator and DON immediately.
- Department heads started safety survey assessments and will have all safety survey assessments completed on all residents that could give a response at north nurse's station.
- Secured unit charge nurse contacting family members of residents on secured unit to complete safety survey for residents that have impaired cognition.
- Administrator will hold Resident council meeting to discuss abuse/neglect for residents that would like to attend.
- All residents that did not attend resident council will be talked to individually by department heads and family will be contacted for residents that have impaired cognition.
- Medical director notified of Immediate Jeopardy in facility.