Inadequate Abuse Policy and Investigation Procedures
Penalty
Summary
The facility failed to fully develop and implement an abuse prohibition policy that includes specific procedures for identifying and investigating abuse. The existing policy, titled "Abuse and Neglect Prevention," outlines the facility's commitment to providing care in an environment free from abuse, neglect, mistreatment, or exploitation. However, the policy lacks detailed guidance on recognizing different types of abuse, such as mental/verbal, sexual, physical abuse, and deprivation of goods and services. This omission leaves staff without clear procedures to identify abuse, neglect, and exploitation of residents, and misappropriation of resident property. Additionally, the facility's policy on investigating allegations of abuse is incomplete. While it requires immediate notification of the administrator and removal of implicated staff from resident care areas, it does not include procedures for handling evidence in cases of sexual abuse. The policy fails to instruct staff on preserving evidence, such as avoiding washing linens or clothing, destroying documentation, or bathing the resident before a forensic examination. This lack of guidance could interfere with thorough investigations by the facility and external authorities. An interview with the Nursing Home Administrator confirmed these deficiencies, highlighting the risk of incomplete investigations and failure to protect residents from further harm.
Plan Of Correction
1. The Abuse Policy was reviewed and updated, including guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The facility staff will be educated on the appropriate abuse procedure including remaining with the resident involved in a potential abuse investigation, secluding/observing the alleged perpetrator if possible safely until police arrive, and preserving an investigation scene including materials and victim for potential testing. Education includes that while the alleged perpetrator is onsite, escort the alleged perpetrator to the nursing supervisor office or lobby area to wait and be available to be interviewed when the police arrive. 4. A random sampling of staff will be interviewed to validate knowledge of Abuse Policy and preserving an investigation scene. Audits will occur daily for 7 days, weekly x 12 weeks with results reported to QAPI for further review.