Failure to Immediately Investigate and Protect Resident Following Abuse Allegation
Penalty
Summary
A deficiency occurred when facility staff failed to immediately investigate an allegation of abuse involving a resident with dementia, anxiety, osteoarthritis, and hypertension. The resident, who had a history of cognitive impairment and required moderate to substantial assistance with activities of daily living, was found with a large, dark bruise on her left forearm after a visit from her husband. 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 noted that the husband admitted to losing his temper during the visit. Despite these reports, the administrative staff member on duty instructed nursing staff not to document the incident or complete witness statements, expressing disbelief in the abuse allegation and deferring any investigation until the following morning. No immediate protective measures were implemented for the resident, and the incident was not reported as required by facility policy. Staff expressed concerns for the resident's safety and fear of retaliation for reporting the incident, but were told by administration to "drop it" and not pursue further documentation or reporting. The facility's own abuse prevention policy required immediate reporting and investigation of any suspicion of abuse, as well as protective actions for the resident. However, the administrative response delayed both the investigation and the implementation of protective measures, leaving the resident at risk for further potential abuse or mistreatment. The lack of timely action and failure to follow established procedures directly contributed to the identified deficiency.