Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct complete and thorough investigations of allegations of physical abuse, neglect, and misappropriation of property for four residents. The facility's policies required the nursing home administrator to investigate and report any allegations of abuse within the required timeframes. However, the facility did not adhere to these policies, resulting in incomplete investigations and failure to notify the Department of the alleged perpetrators. For Resident R120, the facility did not conduct a thorough investigation into an allegation of physical abuse. The resident reported that a nurse attempted to administer an unfamiliar medication and placed her finger in the resident's mouth. Although an alleged perpetrator was identified, the facility failed to notify the Department. Similarly, for Resident R58, the facility did not complete a thorough investigation into the misappropriation of $200. The investigation was not concluded, and the resident's request for reimbursement was not addressed. Resident R22's case involved an allegation of physical abuse where a nurse aide allegedly yanked the resident by the collar. The facility did not document a complete investigation, including interviews with the resident, family members, or other residents. Additionally, Resident R1 reported neglect and disrespectful treatment by staff during an incident involving incontinence. The facility did not investigate this incident as required, further highlighting the failure to adhere to their abuse prevention policies.
Plan Of Correction
1. A PB-22 was completed for Resident R120. Resident R58 was given $200. The reportable incident regarding Resident R22 on August 13, 2024, will be properly investigated. 2. Grievances for the last 4 months will be audited to ensure proper investigations were done. 3. Staff will be educated on the components of this regulation with an emphasis on properly investigating, preventing, and correcting alleged violations. 4. Grievances will be audited to ensure proper investigations 1x week for 1 month, 2x a month for one month, and then 1x a month for 1 month. 5. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.