Failure to Prevent and Report Abuse and Neglect Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse and neglect, as evidenced by multiple incidents involving three residents. One incident involved a female resident with severe cognitive impairment and a male resident, both diagnosed with dementia, who were found engaging in sexual activity. Staff discovered the two residents in a state of undress and engaged in sexual behavior, but did not immediately recognize or report the incident as abuse or neglect. Staff interviews revealed a lack of understanding regarding the reporting requirements for abuse, particularly when both residents involved had cognitive impairments. The incident was not reported to the administrator until the following day, contrary to facility policy and staff training, which required immediate reporting of all abuse, neglect, or exploitation (ANE) incidents. Another incident involved the same male resident, who was found on a separate occasion lying in bed with the same female resident, fully clothed but with his hand on her leg. This event was also not reported as abuse or neglect, as staff did not perceive the behavior as malicious or inappropriate due to the residents' confusion and cognitive status. The lack of documentation and timely reporting of these events indicated a failure to follow established protocols for identifying and responding to potential abuse or neglect, especially among residents with dementia and impaired safety awareness. A third incident involved a nonverbal female resident with severe cognitive impairment who was physically abused by a CNA. The CNA forcefully grabbed and shook the resident's arm after being slapped by the resident, an action witnessed by therapy staff. The resident became emotional and refused further care, with her behavior not returning to baseline until the following day. The incident was reported to the administrator by the therapy staff, and the CNA was subsequently terminated. However, the social worker was not immediately informed, and the incident highlighted a breakdown in communication and adherence to abuse prevention policies among staff.
Removal Plan
- Resident 1 and Resident 2 were immediately separated from each other.
- Residents 1 and 2 received head to toe assessments performed by charge nurse and an emotional assessment performed by social worker.
- The social worker performed trauma informed care assessment.
- Medical Director was notified, and orders obtained for psychiatric services.
- Residents 1 and 2 were evaluated by Psychiatric services and medication changes were implemented.
- Resident 1 and 2 care plans and Kardex were updated to reflect the resident's history of resident-to-resident sexual activity.
- The Business Office Manager was immediately terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds.
- The resident's funds were replaced by the facility.
- All residents with behaviors documented as an incident report and/or in the progress notes will be reviewed to identify any other residents that may exhibit sexually inappropriate behaviors.
- If any behavioral events are identified the resident care plan and Kardex will be reviewed and updated, and interventions will be placed immediately.
- Daily audit of resident behaviors and interventions will be reviewed and noted in resident chart.
- Audits will be conducted for behavioral events.
- The Regional Business Office Director completed an audit for residents trust funds with no discrepancies noted.
- Staff assigned to the secured unit, in which there are consistent staff members, other facility staff including PRN staff and agency staff will be interviewed for any additional incidents or residents that may have been affected by resident-to-resident abuse.
- Education provided to Administrator and Director of Nursing on the abuse policy, investigating and reporting abuse per HHS and CMS regulations.
- Testing and discussion were utilized to assess the knowledge retention of the Administrator and the Director of Nursing.
- Audits by the Regional Business Office Manager.
- Resident Fund Management Service will be audited.
- Education provided to all staff by the Administrator: Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator).
- Education to staff on Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene.
- Staff will be educated to immediately separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing.
- All Facility staff will complete prior to working their next shift.
- New employees and agency staff will be educated upon hire and/or prior to working a shift.
- Knowledge will be verified via test and verbal discussion with affirmative feedback.
- Staff that handle resident funds, Business Office and Human Resources Director will undergo retraining on financial policies, ethical standards, and proper fund management procedures.
- Education provided to Nursing Staff by the Director of Nursing on Resident Kardex that will contain the updated care plans and interventions following behavioral events.
- Staff will be notified of behavioral events through shift-to-shift report and/or the Director of Nursing and/or Assistant Director of Nursing.
- Testing and verbal confirmation are utilized to assess knowledge retention.
- Annual training via Relias regarding resident's rights, theft, misappropriation and abuse.
- All Facility staff, new hire and agency will complete prior to working their next shift.
- Knowledge will be verified via test and verbal discussion with affirmative feedback.
- During daily meeting, Director of Nursing, Assistant Director of Nursing, and/or Designee will review all progress notes and event reports to ensure effective care plans/interventions are in place following any resident-to-resident or other inappropriate behavior.
- Will be reviewed during daily meeting and then weekly thereafter.
- Reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.
- Medical Director informed of this plan at the Ad Hoc QAPI.