Failure to Protect Residents from Abuse and Inadequate Incident Reporting
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration did not implement procedures based on the facility's Abuse, Neglect, and Exploitation policy, despite being aware of multiple residents with unpredictable and aggressive behaviors. Staff repeatedly informed administration about ongoing physical aggression, sexual behaviors, and escalating incidents among residents, but these reports were not acted upon appropriately. Several incidents of resident-to-resident altercations, physical assaults, and inappropriate sexual contact were not reported to the State Survey Agency within required timeframes and were not thoroughly investigated. Documentation and staff statements regarding these incidents were inconsistent, and administration often dismissed allegations based on their own review of camera footage or by questioning the validity of staff reports. Residents with significant behavioral health needs, including those with histories of physical and sexual assault, were not adequately protected. For example, a resident with severely impaired cognitive skills and limited mobility, who had a history of trauma, was subjected to inappropriate sexual contact by another resident known for sexually inappropriate and aggressive behaviors. Despite care plans and trauma assessments indicating the need for increased supervision and interventions, the facility did not implement or maintain adequate measures to prevent further abuse. Staff reported being unable to provide 1:1 supervision due to staffing shortages and felt unsupported by administration, who did not respond to or investigate incidents as required. A pervasive culture of fear and retaliation was reported among staff, who expressed concerns about being terminated or suspended for reporting abuse or cooperating with surveyors. Staff described the dementia unit as chaotic, with insufficient training and high turnover, and reported that administration discouraged open communication and reporting of incidents. Staff statements were often collected by administration in a manner that did not allow for verification or accuracy, and some staff were disciplined or terminated for not aligning with administration's narrative. These failures resulted in multiple deficiencies, including findings of Immediate Jeopardy, and affected the safety and well-being of all residents on the dementia unit.
Removal Plan
- Residents reviewed for proper placement on Dementia Unit. Residents identified as needing placement with active efforts for discharge to proper community placement.
- Admission team to conduct additional review for possible placement on Dementia Unit to ensure resident aligns with unit's goals and bed availability is appropriate.
- Employee Feedback form initiated to solicit feedback and solutions when staff see an opportunity and desire to remain anonymous or not.
- Facility initiated new tool from the Center of Excellence Post-Behavior Root Cause Analysis (RCA) form, providing additional insight to residents when behaviors occur. This tool utilizes a team approach (huddle) to gain knowledge of behaviors/events. Facility Staff completed this tool for those residents with known behaviors on the dementia unit to further care plan any additional interventions that may reduce resident to resident interactions and behaviors.
- Regional Human Resources Director initiated interviews with current staff.
- Administrator of Sister Facility, Social Services background, provided remote review of focused Dementia Unit residents to provide additional suggestions and feedback for interventions, and providing on-site support to assist efforts.
- Current Nursing Home Administrator was placed on administrative leave by Director of Operations.
- Re-Education by Director of Operations to Interdisciplinary Team (Dementia Unit focused) to include use of Post-Behavior Root Cause Analysis (RCA) Form.
- Re-Education by IDT to Facility Staff to include use of Employee Feedback Form. Facility Staff that have not yet received the re-education, and required to complete, will have these items completed prior to their next scheduled shift.
- Monitor: Review of Post-Behavior Root Cause (RCA) completion for behaviors.
- Use of Employee Feedback Form reviewed upon receipt.
- Ad Hoc QAPI held to discuss the above actions taken.