Enforcement actions have been implemented for an Idaho assisted living facility following a series of reports that staff failed to protect residents. The concerns include failing to protect residents from abuse, lack of medication for residents as ordered by physicians, and insufficient staff to meet resident needs.
The facility opened in 2018 as a 32 bed private pay assisted living facility. Sixteen of the beds are designated for memory care for residents with a diagnosis of dementia, Alzheimer’s Disease, or Parkinson’s Disease. According to a report issued by Idaho’s Health and Welfare Facilities Licensing and Regulatory Enforcement System, the facility has had five different administrators in the past five years. They are currently banned from taking new admissions. Beginning August 2, 2021, it has operated under a provisional license due to substantiated reports of “care issue deficiencies” in its operations. In 2019, a year and half before the current allegations, the facility was placed on provisional status, which banned the facility from taking new admissions.
In July 2021, a survey was conducted at the facility by the Idaho Department of Health and Welfare. Based on records and interviews, it was determined that the facility failed to protect two of three sampled residents, with potential to affect 100 percent of the residents living there.
The report stated that a 101-year old resident was reported in April to have bruises on the left arm and eye. The facility was unable to demonstrate that an investigation was conducted or to provide other documentation regarding the bruises. In June 2021, the resident again had bruises reported. Per the August report it was stated by the facility, “There are a few staff members that are very rough with [them] and try to rush their job.”
The report also stated that Adult Protection Services had been to the facility to investigate bruises found on a different resident, and that a third resident had allegedly been punched and was told to “shut up” a few months earlier. There was no written investigation available regarding the incidents. Health and Welfare personnel determined that the facility did not follow its own official policy of suspending the staff member in question or investigating the allegations of abuse.
Additionally, per the survey report, two sampled residents had been admitted to the facility and retained without “sufficient trained staff to manage their physical and verbal aggression.” This led to at least 12 incidents in which one patient endangered both residents and staff, who at times called police and relied on family members to control the patient’s violent behaviors. Staff were interviewed during the survey, and stated that they had not received training regarding how to manage residents with dementia or who exhibit difficult behaviors. A previous administrator of the facility stated that she was aware of the violent behaviors and acknowledged that staff needed training, but that she was too busy to train the staff “due working the floor all the time as a caregiver.”
The survey report also stated “The facility did not put an effective plan into place to protect other residents…there was no documentation that resident-to-resident incidents had been appropriately reported or investigated.”
“The facility has alleged the deficiencies have been corrected,” said Idaho Department of Health and Welfare Public Information Officer Greg Stahl. “An onsite follow-up survey will be conducted by the Department [of Health and Welfare] to verify correction of the deficiencies.”
Issue:
Keeping residents safe and free from abuse, neglect, and exploitation should always be a top priority for administration and staff. Failure to prevent any type of abuse may be considered a breach of resident’s rights and deemed immediate jeopardy, provision of substandard quality of care, and a violation of state and federal regulations, with citations and sanctions applied. In addition, all owners, operators, employees, managers, agents, and contractors of a facility are considered to be mandated reporters and must file a report to both law enforcement and the state survey agency when they become aware of a reasonable suspicion that a crime has occurred against a resident or person receiving care at the facility. If a crime occurs involving serious bodily injury, including criminal sexual abuse to a resident, the incident must be reported immediately, but no later than two hours after forming the suspicion. Under the Elder Justice Act, failure to report a reasonable suspicion of a crime is subject to a civil monetary penalty of up to $300,000 and/exclusion from participation in any Federal healthcare program.
Discussion Points:
- Review policies and procedures for preventing abuse, neglect, and exploitation to ensure they include requirements detailed in F-Tags 600 through 609 in the State Operations manual, Appendix PP. Determine if improvements are needed and update the policies and procedures as necessary.
- Ensure that all staff receive appropriate abuse identification, prevention, investigation, and reporting training during new hire orientation and at least annually thereafter. Document that that the trainings occurred, and file the signed document in each employee’s education file.
- Review training records to ensure that all employees and other agents of the facility receive abuse identification, prevention, investigation, and reporting training during new employee orientation and at least annually thereafter.
