Failure to Immediately Report Alleged Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property were reported immediately to the Administrator as required. In multiple instances, staff did not recognize or report incidents of potential abuse or neglect within the mandated timeframes. For example, two residents with severe cognitive impairment and dementia were observed engaging in sexual activity on two separate occasions. Staff who witnessed or were informed of these incidents did not immediately report them to the Administrator, as required by facility policy and regulatory guidelines. Instead, the incidents were either not reported at all or were reported with significant delay, and some staff did not recognize the events as abuse or neglect due to the residents' cognitive status. Additionally, another incident involved the Business Office Manager confessing to the Marketing Director that she had taken a resident's credit card and used it for personal expenses totaling $3,700. The Marketing Director did not immediately report this confession to the Administrator, instead waiting until the following day. This delay in reporting was contrary to the facility's policy, which requires immediate notification of the Administrator and other authorities in cases of suspected exploitation or misappropriation of resident property. Interviews and record reviews confirmed that staff, including CNAs, LVNs, and administrative personnel, were aware of the requirement to report abuse, neglect, and exploitation immediately but failed to do so in these cases. The Administrator confirmed that she was not notified of the incidents in a timely manner and that staff were expected to follow the facility's reporting policy. These failures resulted in the facility being cited for not protecting residents from abuse, neglect, or exploitation by not ensuring timely reporting and investigation of alleged violations.
Removal Plan
- Resident 1 and Resident 2 were 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 terminated from employment at the facility, and the local police department was notified of the misappropriation of resident funds.
- All residents with behaviors documented as an incident report and/or in the progress notes for the previous 90 days 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.
- 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 based on the immediate jeopardy.
- 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.
- Weekly audits by the Regional Business Office Manager.
- Weekly Resident Funds Management Service audits by the Regional Business Office Manager.
- If a discrepancy is found, it will be investigated by the regional business office manager, facility administrator, and Regional VP of Operations.
- Abuse and Neglect: Types of abuse, including sexual abuse and when/who to report to (immediately & the administrator- abuse coordinator).
- Resident to Resident: Recognizing behaviors, triggers, and how to effectively intervene.
- Staff will be educated to separate the residents and implement 1:1 observation until instructed otherwise by the Administrator and/or Director of Nursing.
- All Facility staff will complete them 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 will undergo retraining on financial policies, ethical standards, and proper fund management procedures.
- The resident will be monitored for aggressive/inappropriate behaviors.
- When no longer exhibiting aggressive/inappropriate behavior that warranted the 1:1 observation the Interdisciplinary Team and Physician will collaborate for the discontinuation of 1:1 observation.
- Reconciliation of resident trust fund by the Business Office Manager/Regional Business Office Manager.