Failure to Investigate Alleged Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation related to an allegation of mental abuse involving a resident diagnosed with diabetes mellitus, hypertension, and bipolar disorder. The incident occurred when the resident requested his scheduled medication after returning from a smoke break, leading to a verbal altercation with a registered nurse. The resident reported feeling intimidated by the nurse, who allegedly yelled at him. The facility's documentation included a grievance form and statements from involved parties, but the investigation was not comprehensive, and the incident was not reported to the department of health in a timely manner. The facility's documentation identified the registered nurse as the perpetrator of the verbal altercation, yet the follow-up investigation submitted to the State Survey Agency did not acknowledge this, nor did it determine whether the allegation was substantiated or unsubstantiated. Interviews with staff confirmed the occurrence of the verbal altercation, but the facility failed to submit a thorough investigation or a PB22 report form for the alleged abuse. This lack of a comprehensive investigation and timely reporting constitutes a deficiency in the facility's handling of the incident.
Plan Of Correction
1. The facility has completed a thorough investigation related to the allegation of mental abuse for Resident R1. 2. Current residents with allegations of alleged mental abuse will be reviewed for the past 14 days to verify a thorough investigation has been conducted. 3. The NHA or designee will re-inservice the management team on how to conduct a thorough investigation. Residents with allegations of mental abuse will be reviewed during morning meetings to verify a thorough investigation has been conducted. 4. The NHA or designee will conduct audits of allegations of alleged weekly x4 weeks, then monthly x2 months. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.