Failure to Investigate Abuse Allegations and Prevent Further Resident Exposure
Penalty
Summary
The facility failed to thoroughly investigate an initial injury of unknown origin and an allegation of mistreatment for one resident, as well as failed to prevent further access between a resident and an employee with confirmed abuse findings. Specifically, the facility did not complete a comprehensive investigation into the circumstances surrounding the injury and mistreatment, as required by their abuse prevention policy. The policy mandates timely, thorough, and objective investigations, including identifying and interviewing all involved persons, such as the alleged victim, perpetrator, witnesses, and others with relevant knowledge, and providing complete documentation of the investigation. Additionally, the facility did not ensure the protection of a resident by allowing continued access to an employee who had confirmed abuse findings, contrary to the policy that requires immediate removal of the alleged perpetrator from the facility and schedule pending the outcome of the investigation. These failures were identified during the review of two specific intakes and involved at least two residents, one of whom had an injury of unknown origin and another who was exposed to an employee with a history of abuse.
Plan Of Correction
F610 Investigate/Prevent/Correct Alleged Violation It is the practice of the facility, in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated, and the contracted CNA involved in the incident no longer works at the facility. Element 2: Residents with allegations of abuse have the potential to be affected. Investigation files of those residents with open investigations have been reviewed to validate a thorough investigation was conducted to include implementation of corrective measures to prevent further potential abuse. No additional instances as identified in the citation were identified. Residents with BIMS score of 12 or higher were interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS score of 11 or lower will be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 3: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility managers were educated on the abuse policy with an emphasis on completing a full and thorough investigation and on corrective actions to prevent further potential abuse. The Quality Assurance Consultant will in-service Unit Manager and Director of Nursing regarding maintaining all evidence of an investigation. Element 4: Audits on allegations of abuse will be completed weekly by the Administrator/designee to validate a full and thorough investigation was completed, corrective actions were taken to prevent further potential abuse, and that evidence of the investigation is maintained. Results of the audits and interviews will be submitted to the QAPI committee for further review and recommendations. Element 5: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.