Failure to Follow Abuse Prevention Policy and Staff Training Requirements
Penalty
Summary
The facility failed to follow its abuse prevention program policy and procedure in two key areas: timely review of criminal history background checks for new admissions and ensuring staff were educated and understood the abuse prevention program. Specifically, the facility did not check and review the criminal history background check within 24 hours of admission for one resident, despite the policy requiring this step. The resident's criminal history record was dated two days after admission, indicating the process was not completed as required. Additionally, two staff members, including an agency LPN and the Maintenance Director, were not educated or fully aware of the facility's abuse prevention program policy and procedure. The agency LPN, on her first day, was unaware of the abuse coordinator and had not received any abuse-related in-service or education. The Maintenance Director also reported not receiving specific training on how to handle abuse situations, which he believed contributed to the recurrence of a physical altercation between two residents. The deficiency was further evidenced by two physical altercations between residents with histories of mental health diagnoses, including schizophrenia and bipolar disorder. After the first altercation, both residents were kept in the same location, leading to a second fight. Multiple staff and residents confirmed that the second incident could have been prevented if the residents had been separated. The lack of staff training and failure to follow abuse prevention protocols contributed to the escalation and recurrence of resident-to-resident physical abuse.