Failure to Report Neglect and Ensure Safe Environment
Summary
The facility failed to report an allegation of neglect involving a resident who suffered a major injury due to an unsafe environment. The incident involved a resident in the memory care unit who experienced an unwitnessed fall in the hallway, resulting in a significant injury that required surgical intervention. The facility's policy mandates immediate reporting of such incidents, especially when they involve serious bodily injury, but this was not adhered to. The resident, who had a history of poor safety awareness and was residing in the memory care unit, tripped and fell in a hallway with rough and uneven concrete. This area was a known high-traffic zone and had a raised drain cap, which posed a hazard. Despite the known risk, the facility did not take timely action to repair the flooring hazard, which contributed to the resident's fall and subsequent injury. Interviews with facility staff, including the Director of Nursing and the Director of Maintenance, revealed a lack of prompt reporting and inadequate measures to ensure a safe environment. The Director of Nursing did not report the incident, believing the plan of care was followed, while the Director of Maintenance acknowledged the flooring issue but only addressed it after the incident occurred. The facility's failure to report the incident and address the environmental hazard in a timely manner led to the deficiency.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Nursing Home Administrator/Coordinator re-educated on ensuring that allegations of neglect or mistreatment are reported according to federal guidelines time frame. Late report completed for Resident # 6. Resident #6 no longer resides at the facility. 2. Identification of other residents having the potential to be affected: Care Plan Coordinator/Designee completed quality review of residents who sustained in past 6 months. No newly affected residents identified. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Education for all staff on Neglect and a position has been created for a facility risk manager, and we are currently recruiting for the position. A daily Risk Management Meeting initiated at daily clinical meeting, to include attendance of the interdisciplinary team with NHA oversight. Risk events including alleged violations involving possible neglect, mistreatment, injuries of unknown source and misappropriation will be reviewed by Administrator/Risk Manager/Designee to ensure all reportable events meet the time frame guidelines for reporting. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Administrator/Risk Manager/Designee will conduct an audit of risk events to monitor all risk events for alleged violations including possible neglect, mistreatment, injuries of unknown source and misappropriation and make certain violations are reported five times a week X 4 weeks, 3 times a week X 4 weeks, twice weekly X 4 weeks, then weekly and as indicated. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Penalty
A resident reported feeling sexually harassed and abused by a male OTA after he entered her room while she was undressed. The incident was communicated to supervisory staff, but no report was filed with state agencies and no investigation was conducted, despite facility policy and regulatory requirements for immediate reporting and investigation of such allegations.
A resident who was totally dependent on staff for toileting was found covered in feces after reportedly being left unassisted for several hours, despite requesting help. The incident was documented by staff and reported internally, but the required notification to state agencies was not made, as acknowledged by the facility's administrator.
A resident accused a CNA of causing bruises during care, but the facility failed to report the allegation within the required two-hour timeframe. The incident involved the resident becoming combative, and the CNA calling for help. Despite staff awareness, the report was delayed, leading to a deficiency finding.
A resident at an LTC facility experienced neglect when a nurse attempted to administer a discontinued medication and placed a dropped pill back in the cup. The resident, who primarily spoke Spanish, reported the incident to the MDS Coordinator, but the facility failed to report the allegations to the State Agency and protect the resident during the investigation. The Director of Nursing and the nurse involved allegedly yelled at the resident, and the nurse was reassigned to the resident despite her request for a different caregiver.
Two residents reported incidents of neglect involving CNAs, which were not properly reported or investigated by the facility. One resident was yelled at by a CNA for needing to be changed, and another felt threatened when a CNA allegedly raised her hand as if to hit him. The facility failed to report these incidents to the State Agency and did not conduct a thorough investigation, leading to a deficiency in handling allegations of neglect.
Failure to Report and Investigate Alleged Sexual Harassment
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the reporting of a reasonable suspicion of a crime, as required by federal and state regulations, for one resident out of four sampled. The deficiency centers on an incident involving a resident who reported feeling sexually harassed and abused by a male Occupational Therapist Assistant (OTA) after he entered her room while she was undressed. The resident stated that she told the OTA to leave, which he did, and subsequently refused therapy with him. She reported the incident to a female supervisor and the DON, expressing that she did not want the OTA in her room anymore and described her feelings of harassment and abuse. Interviews with facility staff revealed inconsistencies in the communication and handling of the resident's allegation. The Director of Rehabilitation stated that the resident reported the incident to her, and she subsequently interviewed the OTA and relayed the information to the DON, who is the facility's abuse coordinator. However, the DON denied receiving any report of sexual harassment or abuse from the Director of Rehabilitation, stating that the only concern brought to her attention was the resident's preference for a therapy schedule and not wanting certain therapists. The DON confirmed that if an allegation of abuse or sexual harassment had been reported, she would have suspended the staff member, reported the allegation, and initiated an investigation, none of which occurred. A review of the facility's state agency reportable log showed no evidence that a report was filed with state agencies or that an investigation was conducted regarding the resident's allegation. The facility's policy requires staff to report any allegations of abuse, neglect, exploitation, or mistreatment immediately to the appropriate personnel and to state agencies within the required timeframe. Despite these policies, the incident involving the resident and the OTA was not reported or investigated as required, resulting in noncompliance with federal and state regulations.
Plan Of Correction
N917 Resident #3 abuse allegation was reported, an investigation conducted, and investigative findings confirm unsubstantiated for sexual abuse. Resident #3 discharged home as planned and no longer resides in the facility. The facility DOR and Staff C no longer are employed at the facility. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Like resident interviews conducted with no reported concerns regarding sexual abuse or care concerns. Process of reporting abuse, neglect, and exploitation reviewed with residents at Resident council by 7/12/2025. Staff interviews and education conducted to ensure no reported allegations of abuse, neglect, or exploitation. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. The administrator educated the DON on reporting requirements of abuse, neglect, and exploitation allegations with competencies. 2. The administrator and/or designee educated staff on reporting requirements to the facility abuse coordinator of allegations of abuse, neglect, and exploitation with staff competencies. 3. Newly hired staff will be educated on reporting requirements to the facility abuse coordinator of abuse, neglect, and exploitation allegations and the facility abuse coordinator. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents on each unit. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The administrator and/or designee will conduct random 10 staff interviews for competencies on reporting allegations of abuse, neglect, and exploitation. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met. This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
A facility failed to report an allegation of neglect to the appropriate agencies as required by state and federal regulations. The incident involved a resident who was found covered in feces, with evidence indicating he had been left in that condition for several hours. The resident, who was totally dependent on staff for toileting, reported that he had been asking to be changed all morning and had not received assistance until the afternoon shift began. The staff member assigned to the resident during the morning shift had already left the building before the afternoon aide discovered the situation. Documentation in the resident's clinical chart and care plan confirmed his dependence on staff for activities of daily living, including toileting. A "Teachable Moment" form was found in the personnel file of the CNA assigned to the resident, describing the incident and noting that the resident had been left in feces for an extended period. However, the form was unsigned, and the Human Resource Director was unaware of its origin. The afternoon CNA who discovered the resident reported the incident to the nurse and unit manager, and also submitted a written statement and grievance report detailing the neglect. Despite these reports and documentation, the incident was not reported to the state agency as required. The Nursing Home Administrator acknowledged that the care provided was not appropriate and had the potential to be considered neglect, but confirmed that the incident was not reported through the required channels. The process for reporting such allegations was described, but in this case, it was not followed.
Plan Of Correction
1. Resident #9 was assessed by nursing and social services and no adverse effects were noted. Resident remains in the center. Staff B was terminated. Resident #9 interviewed by NHA and resident stated that he felt safe in the center and had no additional concerns at the time of the interview. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed any other residents or were abused at any time. Skin assessments were completed for residents with less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. Mistreated, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of Nursing is the designated coordinator. Once an allegation of mistreatment is reported, the Executive Director, as the coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notifications of Law Enforcement if a reasonable suspicion of crime has occurred. A review of Resident #9's clinical chart documented an admission of his diagnosis list included but not limited to Type 2 diabetes. A review of a dated document showed a score of 13, with a comment "Intact response." A review of Resident #9's clinical chart, the Care Plan, documented a focus area: Resident #9 has an ADL (Activity of Daily Living) self-care performance and is at risk for decline. Interventions included: Toilet Use: The resident is totally dependent on staff for toileting. A review of Staff B, Certified Nursing Assistant's... 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Delayed Reporting of Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect within the required two-hour timeframe for a resident. The incident involved a Certified Nursing Assistant (CNA) and a resident, where the resident accused the CNA of grabbing her arm and causing bruises. The facility's policy mandates immediate reporting of such allegations, especially if they result in serious bodily injury, but the report was delayed. The incident began when the resident requested assistance from the CNA, who was attending to another resident at the time. Upon returning to assist the resident, the CNA reported that the resident became combative, grabbing the CNA's shirt and hitting her. The CNA called for help, and other staff members responded. The resident later alleged that the CNA had grabbed her arm tightly, causing bruises. The incident was not reported to the Nursing Home Administrator until several hours later, despite staff being aware of the situation earlier in the day. Interviews with staff revealed that the CNA involved was suspended during the investigation, and the Director of Nursing was informed of the incident later in the afternoon. The delay in reporting was attributed to a lack of immediate investigation and communication among staff. The resident's care plan noted self-neglect behaviors and a history of refusing care, which may have contributed to the incident. However, the facility's failure to adhere to its reporting policy resulted in a deficiency finding.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect, and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.
Failure to Report Allegations of Neglect and Protect Resident
Penalty
Summary
The facility failed to report allegations of neglect and protect a resident during an investigation. A resident, who had been at the facility for over two years, experienced an incident where a nurse attempted to administer a discontinued medication and another medication that the resident preferred to take every other night. The resident, who primarily spoke Spanish, tried to communicate with the English-speaking nurse about the medication error. During the interaction, a pill fell on the floor, and the nurse placed it back in the cup with the other medications. The resident refused to return the pills until she spoke with a supervisor, but the nurse left without calling one. The resident reported the incident to the MDS Coordinator the following morning, who then informed the management. The Director of Nursing (DON) and the nurse involved confronted the resident, allegedly yelling and calling her a liar. The resident felt disrespected and reported the incident to the Department of Children and Families (DCF), who visited the facility and took pictures of the pills. Despite the resident's request not to have the same nurse assigned to her again, the nurse was reassigned to her, causing the resident distress and fear of retaliation. The facility's reportable log did not show any neglect allegations reported by the resident. The Administrator acknowledged the DCF visits but did not consider the incidents as neglect, citing the time frame of care as a factor. The facility's policy on neglect and abuse was not followed, as the allegations were not reported to the State Agency, and the resident was not protected during the investigation.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Upon identification of the deficiency, the facility immediately self-reported the allegation to the State Agency. The accused nurse was removed from the schedule pending an investigation. Resident #56 was assessed by social services to ensure emotional and physical well-being. Supportive interventions, including psych services and reassurance, were provided. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. A review of grievances for the last 60 days was conducted by the Interdisciplinary Team, which included the Administrator, Social Services, DON, RVP, and Regional Nurse to determine if any other allegations of neglect had been unreported or inadequately investigated. Any identified concerns were immediately self-reported and addressed. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: The Coordinator and Director of Nursing were educated on by the RVP on reporting requirements utilizing FHCAs Decision Tree. Starting on all staff will receive mandatory training on identification, mandatory reporting, and investigation protocols. All staff will be in-service by. Any staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will conduct audits of five grievances per week for two months, followed by ten grievances per month for a minimum of three additional months, to ensure appropriate reporting and implementation of protective actions. Results of the audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. (e) The date of compliance is.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to prevent and timely report allegations of neglect for two residents. Resident #7, who was dependent on staff for toileting hygiene and needed substantial assistance for personal hygiene, filed a grievance after a CNA yelled at her for needing to be changed. The grievance was not reported to the State Agency, and the Administrator was unaware of it until it was brought to her attention during the survey. The grievance was not investigated as required, and the Social Service Director and Unit Manager were also unaware of the complaint. Resident #1, who had a history of right lower extremity issues and required substantial assistance for hygiene, reported an incident where a CNA allegedly raised her hand as if to hit him. The resident felt threatened and used foul language in response. The incident was reported to the Weekend Supervisor and the DON, but no immediate investigation or skin check was conducted. The DON later determined it was a customer service issue and did not report it as an abuse allegation. Witness statements were not collected from staff present during the incident, and the facility's investigation was incomplete. The facility's policy required immediate reporting of abuse or neglect allegations, segregation of the suspect from residents, and a thorough investigation. However, these procedures were not followed in the cases of residents #1 and #7. The facility failed to document and report the incidents to the State Agency within the required timeframe, and the investigation process was not adequately conducted, leading to a deficiency in handling allegations of neglect.
Plan Of Correction
1) On Resident #7 reported grievance was submitted to AIRS system by NHA. (2) A comprehensive review of all grievances for the months of and was conducted by Regional Vice President of Operations, Executive Director and Social Services Director to ensure adherence to facility policy. No new issues found. (3) 1. Education provided by RVPO to SSD and ED on grievance and reporting process. 2. Education provided to all staff on the grievance and reporting process, postings and placement of grievance forms. 3. All grievances are reviewed by ED, SSD and DON daily; supervisor calls and reviews grievances with ED, SSD, DON or designee on weekends. 4. Grievance policy reviewed by Executive Director in resident council meeting on. 5. A quality review is conducted weekly by ED/DON or SSD on grievances and reportable incidents. (4) A quality review will be completed by the Executive Director/designee of grievances and reportable incidents, to ensure the policy/process is adhered to, 5 times a week for 4 weeks, and then weekly for 2 months. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
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