Failure to Protect Cognitively Impaired Resident from Potential Abuse and Inadequate Incident Reporting
Penalty
Summary
Staff failed to respond appropriately and provide adequate supervision to prevent potential abuse and/or mistreatment of a cognitively impaired resident. The resident, who had diagnoses including dementia, anxiety, and osteoarthritis, was known to have moderate cognitive impairment and required staff assistance with several activities of daily living. The resident's care plan documented a history of bruising and traumatic events, and directed staff to observe for bruising and avoid discussing traumatic events with the resident. On the evening of the incident, the resident's husband visited and assisted with undressing, during which a large, dark bruise was observed on the resident's left forearm after he left. Multiple staff members reported that the resident stated her husband (whom she sometimes referred to as her brother) had gotten mad and grabbed her arm, causing the bruise. Staff also reported that the husband admitted to losing his temper. Despite these reports, the administrative staff member on call instructed staff not to document the incident or complete witness statements, expressing disbelief in the abuse allegation and deferring investigation until the following day. The incident was not reported as an allegation of abuse, and no immediate protective measures were implemented. Subsequent interviews with staff revealed concerns for the resident's safety and fear of retribution for reporting the incident. The facility's own abuse policy required prompt reporting and protection of residents, but this was not followed. The lack of timely response, failure to report, and inadequate supervision placed the resident at risk for potential abuse and/or mistreatment.