In this edition of The State of IJs, we’re digging into an Immediate Jeopardy (IJ) citation issued to a nursing home in Delaware. Remember, IJ citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes.
Today’s IJ situation focused on reporting allegations of abuse to avoid a deficiency at F609 Reporting of Alleged Violations.
Compliance Insights
Today’s IJ discussion is about something that most providers have either experienced or have heard about from their colleagues. Here is what happened in this IJ situation:
There was a witness to a staff member/CNA abusing a resident – the assigned CNA was witnessed to stick out her tongue at a resident, (who did have a known history of being aggressive), but the CNA also took three swipes towards the resident’s head in response to the resident calling her a name.
The witnessing CNA reported what she had seen to the Licensed Practical Nurse (LPN) on the date it occurred. The witnessing CNA did return to the resident’s room and noted that the resident was fine. The LPN did not report this incident to the Abuse Coordinator at that time. It is not clear how the Unit Clerk obtained information regarding this event, but thought to report the incident and “forgot” after taking care of another resident – this was the day after the incident had occurred. The incident was actually reported 4 days after the occurrence. Obviously the two-hour abuse allegation reporting window was not met related to staff failure to follow proper reporting procedures. When this situation finally came to light, it was reported. The involved CNA was suspended during the investigation and was subsequently terminated.
During an interview as part of the investigation process, the CNA stated she was “playing” with the resident. This is not an acceptable interaction with a resident and trying to defend it as “playing” is simply wrong.
The facility also implemented a comprehensive Removal Plan 4 days after the event and included all of the right things that normally would have been initiated immediately after an abuse event has been reported. What were the actions taken to address the situation? The facility was comprehensive.
- The facility brought the failure to report to the QAPI Committee and implemented a PIP in response to the reporting failure
- The plan included a policy and procedure review
- Staff reeducation on Abuse protocols
- A monitoring plan of random review of residents for abuse was initiated for a determined period of time
During the State Agency’s investigation – approximately 8 months after the incident was reported – the facility was cited for an Immediate Jeopardy Past Non-Compliance and determined to be substantial compliance 10 days after the incident actually took place. Such an outcome is not routine.
What we should all learn from this incident is staff need to understand their abuse reporting responsibilities – if you are not sure if it is a reportable incident, share that information with your immediate supervisor for follow-up discussion with the Abuse Coordinator and do it immediately. Remember, in this case, the CNA involved in this abuse allegation, remained on duty for a period of time until they were suspended.
Reminder:
It does not hurt an organization to periodically check staff knowledge related to the components of the Abuse Prevention Program. If the staff does not understand the important component of their reporting responsibilities, how do you protect the involved resident and any other resident from further abuse? All staff should be aware of the two-hour window to report an allegation of abuse.
The Best Way to Handle an IJ? Prevent It.
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