Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving three residents, leading to a potential risk of further abuse. Resident #105, who had diagnoses including depression, paraphilia, unspecified dementia with psychotic disturbance, and anxiety, was involved in an incident with Resident #106. Resident #106 reported feeling harassed and fearful after Resident #105 approached her aggressively on two occasions, despite staff intervention. LPN H, who witnessed the incidents, did not report them immediately but later informed the Nursing Home Administrator (NHA) A, who decided against documenting the incident to avoid affecting admission referrals for Resident #105. Additionally, a family member of Resident #107's roommate reported concerns of potential sexual abuse by a male staff member. Unit Manager (UM) E was informed of these concerns but did not conduct a full investigation, as it was determined there was no immediate concern due to limited male staff presence. The Director of Nursing (DON) B confirmed that a full investigation was not completed for the sexual abuse concerns involving Resident #107. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of all alleged violations to the facility administrator and state agency. However, in these cases, the facility did not adhere to its policy, as the allegations were not thoroughly investigated, and the state agency was not notified. This failure to act according to policy resulted in a deficiency citation for the facility.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/25 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.