Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that further potential harm was prevented while investigations were in progress. Multiple incidents involving resident-to-resident altercations were not properly investigated, and required documentation such as written statements and State Provider Investigation Reports were not completed as per facility policy. For example, one resident was hit in the back by another, another resident was grabbed and scratched, and a third incident involved a resident being pushed to the ground, resulting in injury. In another case, a resident was punched in the face, causing a non-displaced nose fracture. In each of these cases, the facility did not gather written statements or complete the required 5-day investigation reports. The report details that the facility did not analyze the circumstances of these incidents to determine if changes to policies or procedures were needed to prevent recurrence. There was also a lack of review and documentation of corrective actions for these incidents. The Administrator and other staff demonstrated a lack of knowledge regarding the required reporting timeframes and procedures for investigating and documenting abuse allegations. Interviews revealed that the Administrator was unaware of the 2-hour reporting requirement and the necessity of completing and submitting the 5-day investigation report to the state agency. Additionally, the facility's own policy on resident-to-resident abuse, which outlines steps for investigation and reporting, was not followed. Several residents involved in these incidents had significant cognitive impairments or psychiatric diagnoses, such as Alzheimer's disease, dementia, bipolar disorder, and schizoaffective disorder. The incidents resulted in physical injuries, including a nose fracture and a vertebral compression fracture, as well as psychosocial harm. The facility's failure to follow its own policies and regulatory requirements for investigating and reporting abuse led to an Immediate Jeopardy situation, as residents were placed at risk for further harm, unrecognized abuse, and emotional distress.
Removal Plan
- Residents had interventions put in place including separation from other residents when resident to resident altercations occurred.
- Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient.
- Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behaviors were noted.
- Resident #2 & Resident #1 were separated from one another and both sent to the ER, while in the ER staff made referral to inpatient behavioral hospital. Both Resident #2 & #1 were admitted to inpatient behavioral hospital.
- Care plans reviewed and updated as needed for incidents reported.
- Staff separated residents and monitored for any additional behaviors or until placement occurred for residents. When no additional behaviors occurred, residents were removed from monitoring.
- In house psychiatric services are contacted with behavioral incidents for evaluation and additional treatment if needed.
- All staff will be re-educated on the Abuse/Neglect Policy and the procedures for reporting, documenting, and investigating all allegations of abuse or neglect; in-services started by the Administrator, the DON, nurse manager, and department managers and will continue until all staff were in-serviced and no staff will work their scheduled shift until in-serviced.
- Inservices to discuss resident behaviors, how to de-escalate and prevention; all staff must be in-serviced before working their scheduled shift.
- Facility has asked contact from local behavioral hospital to conduct training with staff during mandatory Inservice.
- Inservices related to reporting allegations of abuse to Administrator and DON immediately. Re-education will continue; no staff is to work their scheduled shift until in-services are completed for them.
- RDO trained Administrator and DON on investigating, prevention, and report abuse/neglect allegations.
- RDO in-serviced Administrator/DON with this information.
- Staff in-services were started with staff over completing witness statements, abuse and neglect (timely reporting and types of abuse), safety surveys when state surveyors mentioned these issues.
- Revision of policy and procedure was loaded into staff communication system so everyone who has already signed in-services was made aware of revision to policy.
- Regional Director of operations visits the facility on monthly basis and will follow up with the Administrator/DON with each self-report to ensure investigation of self-reports are completed in timely manner and 3613 is submitted to state with all the documentation gathered with investigation. All communication between monthly visits is to be sent through email.
- In-services for documentation including witness statements and monitoring for required documentation that is needed with incidents, including witness statements and monitoring, all staff will be in-serviced prior to start of shift.
- Nurse manager started Inservice for all Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in-services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that is required for investigation. This information was also included in facility communication for all nurses.
- Department heads started safety survey rounds for residents.
- Charge nurse on secured unit contacting family members for residents that reside on the secured unit to complete safety survey for residents that have impaired cognition; facility is awaiting phone calls from 4 family members where facility left voicemail.
- Resident council scheduled with residents to discuss changes to policy and what is required when these types of allegations are reported.
- Department heads will speak to each resident that did not attend resident council meeting individually and for those that have impaired cognition family members will be contacted.
- The Administrator and DON will personally review all incident reports and abuse allegations within 2 hours of occurrence to ensure timely reporting, investigation, and documentation.
- The Social Services Director and Unit Managers will monitor daily for any new behavioral incidents and report immediately to administration.
- The DON or Designee will complete a daily audit of all incident logs for 30 days, then weekly for 90 days.
- Audit results will be documented and discussed in QA meeting for review and corrective follow-up.
- Any staff member who fails to report, investigate, or document an allegation of abuse appropriately will be subject to disciplinary action up to and including termination.
- The QA Committee will review all incident reports and abuse allegations monthly for 90 days to ensure that each incident is investigated, documented, and reported according to policy.