Three incidents occurring in a Georgia long-term care center since May 2020 are being investigated by a local police department. The incidents involve assault, elder abuse, injuries, and deaths.
The incident triggering the initial police investigation involved an employee of the facility accused of pushing an 81-year-old resident during an argument causing him to fall, suffer a broken hip, and lose his ability to walk. The resident was sent to a rehabilitation center to recover, but contracted COVID-19 and died. The employee has since been arrested and charged with aggravated battery and felony elder abuse.
In May, a 79-year-old resident was discovered on the floor after a fall with a cut to his head and massive bruising. The director and manager did not notify the resident’s family and did not call 911 for EMS assistance. The deterioration of the resident’s health was later noticed by an agency nurse who contacted the family. The family decided to remove the resident from the facility but, on the day of his discharge, the facility’s manager, without having performed a swallowing test, gave the resident a doughnut, causing him to choke. He died two days later, and the autopsy found pieces of the dough from the doughnut still lodged in his throat. The manager and director of the facility were arrested and charged with felony neglect of an elderly person.
Another incident in October involving a resident-to-resident altercation resulted in one resident falling or being knocked to the floor and the other resident having contusions to his head. The facility sent the two residents to the hospital but did not notify their families.
The facility in now under new management with all new staff members. Officials indicated that the administrative staff are fully cooperating with the continuing investigation efforts of the police.
Compliance Perspective
Issue
Failure to properly notify residents’ families or responsible parties and to thoroughly investigate reportable incidents as required by the Centers for Medicare & Medicaid Services may be deemed a breach of residents’ rights to be free from abuse and neglect and considered provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points
- Review policies and procedures to ensure that protocols prohibiting physical reactions directed toward a resident by a staff member, no matter the situation, are implemented. Evaluate the facility’s process for conducting fall risk evaluations to prevent and respond to residents’ falls. Determine that policies are in place and followed for notifying families and physicians of incidents or a change in status experienced by a resident.
- Train staff regarding abuse and neglect, including the prohibition of any physical response, whether provoked or not, by a staff member toward a resident. Teach staff the requirements for appropriate notification of families when residents experience a negative event.
- Periodically audit residents’ fall risk evaluations to determine if adequate prevention and intervention plans are included in care plans and are being followed. Review incident/accident forms to learn if investigations are thorough and follow up activity meets both regulatory and facility policy requirements.
