Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for one of the two residents reviewed, specifically Resident R46. The facility's policy on 'Abuse, Neglect, and Exploitation' requires complete documentation of investigations, including interviews with all involved parties. However, there was no documented evidence that Resident R46 was interviewed regarding the alleged incident of abuse. The incident involved RN Employee E14 and LPN Employee E15, who reportedly made inappropriate comments to Resident R46 when the resident inquired about delayed pain medication. Despite the facility's policy, the investigation report dismissed Resident R46 as a credible source based on past behaviors and medical history, without attaching any interview documentation. Resident R46, who was admitted to the facility with diagnoses including cerebrovascular accident, anxiety disorder, depression, and chronic osteomyelitis, was cognitively intact as indicated by a BIMS score of 14. The incident occurred when Resident R46 was reportedly given a hard time by the nursing staff, leading to an escalation. The facility's failure to conduct a thorough investigation was confirmed by the Nursing Home Administrator and Director of Nursing, highlighting a deficiency in adhering to the required investigative procedures.
Plan Of Correction
Resident R46 was discharged to another facility and unable to be interviewed. The facility has determined that all residents have the potential to be affected if allegations of abuse are not investigated in a timely manner. An in-service education program was conducted by the Director of Nursing Services and the Administrator with direct care staff addressing circumstances that require reporting for timely investigations, and their responsibilities related to investigations. Policy and education on Resident Abuse Prevention and Reporting: The Director of Nursing Services, or designee, will review nursing notes five days per week to identify any allegations of abuse weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.