Failure to Investigate Allegation of Resident Mistreatment
Summary
The facility failed to implement its policies and procedures for investigating allegations of neglect and mistreatment, as evidenced by an incident involving a resident who reported that a male resident entered her room and attempted to get into bed with her. The resident, who has a diagnosis of aphasia and communication difficulties, expressed feeling scared and unable to sleep following the incident. Despite the resident's report, the Director of Nursing (DON) did not interview the resident, notify her family, or conduct interviews with other residents on the unit. The DON also failed to inform the Administrator of the allegation, believing that the incident was likely a mistake and that a 'STOP' banner across the resident's doorway was sufficient to ensure her safety. The report highlights that the facility's policy on Neglect, Mistreatment, and Injury of Unknown Origin (ANEMMI) requires immediate reporting and investigation of such events, which was not adhered to in this case. The Administrator acknowledged that an incident of this nature could require reporting, depending on the situation. Additionally, the Hospice Director confirmed that the resident's daughter had reported the incident to the DON, yet no further action was taken. The lack of a thorough investigation and communication with relevant parties demonstrates a failure to follow established procedures for handling allegations of neglect and mistreatment.
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. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 1 was immediately assessed by a licensed nurse. No concerns were noted related to the alleged deficient practice. Resident #1's care plan was reviewed and revised to include a stop sign on her doorway to deter any other residents from entering her room. Social Service Director completed an assessment for resident #1. No concerns were noted related to the alleged deficient practice. A grievance was filed on resident #1's behalf. A thorough investigation was conducted regarding the allegation of a male resident entering resident #1's room. Results of the investigation did not rise to a level of meeting reporting criteria. The Administrator and Director of Nursing were re-educated by the Regional Nurse Consultant on facility policy and procedures regarding reporting and investigation. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; A quality review was completed by Director of Nursing/designee on current interviewable residents regarding neglect, with a focus on other residents entering their rooms. No additional residents were found to be affected by the alleged deficient practice. The Director of Nursing/Designee completed a quality review of current resident progress notes for the past 7 days to identify any areas of concern that may require additional investigation. No further concerns noted. The Director of Nursing/Designee completed a quality review of facility grievances for the past 30 days for any areas of concern that may require additional investigation. No further concerns noted. A quality review was completed by Director of Nursing/Designee of current residents to identify any resident who may have the potential to enter other residents' rooms. Care plans were revised as appropriate. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current facility staff were educated on the components of N040 with an emphasis on reporting and investigation by the Director of Nursing/Designee. Current nursing staff were educated on characteristics and redirection techniques. Newly hired nursing staff will be educated on characteristics and redirection techniques by the Director of Nursing/Designee at orientation as a part of the systematic changes. Newly hired staff will be educated on the components of N040 with an emphasis on reporting and investigation by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee will conduct audits of 10 current residents' nursing progress notes 3 times a week for 4 weeks, then 1 time a week for 4 weeks, then 2 times weekly for 4 weeks, and then weekly for 4 weeks to ensure response/investigation for any potential allegations that meet federal reporting requirements. The Administrator/Designee will conduct audits of grievances 3 times a week for 4 weeks, then 2 times a week for 4 weeks, and then weekly for 4 weeks to ensure a response/investigation for any potential allegations that meet federal reporting requirements. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Penalty
Three residents with wounds requiring dressing changes were found to have dressings that were not labeled with the required date, time, or staff initials, contrary to facility policy and professional standards. Staff interviews confirmed that labeling is expected after care, but observations showed this was not consistently done.
Failure to Label Dressings per Facility Policy
Penalty
Summary
The facility failed to follow its own resident care policies regarding the labeling of dressings, as required by their written procedures and professional standards of practice. Observations revealed that three residents had dressings or bandages that were not dated, timed, or initialed as specified in the facility's policy. Specifically, one resident was observed with an occlusive dressing on the left side that was not dated, another resident had three undated dressings on the right lower extremity, and a third resident had a dressing on the lower left lateral area with no date, time, or initials. These findings were confirmed through interviews with staff, who acknowledged that the expectation is to label dressings with the date and initials after care is provided. Record reviews showed that all three residents had medical conditions requiring wound care, such as wounds on the lower extremities and other chronic diagnoses. The facility's own policy and staff interviews confirmed that labeling dressings is a required step in the care process. However, the observed failure to consistently label dressings as per policy demonstrated noncompliance with both facility procedures and professional standards of practice.
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