Failure to Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from abuse after an allegation of staff-to-resident abuse was made. The resident, who had dementia with moderate cognitive impairment and difficulty expressing themselves, reported to an LPN that staff had hit them during the previous night. The LPN did not report the allegation to the Nursing Home Administrator (NHA) or initiate an investigation, as required by facility policy. Instead, the LPN dismissed the resident's report as a dream or misconception of reality, without clear justification for this determination. The resident later provided a detailed description of the alleged perpetrator and expressed fear and distress during interviews. Observations confirmed that a nurse aide matching the resident's description was present in the facility. Additional interviews with staff revealed ongoing concerns about the conduct of certain agency aides, including allegations of yelling at residents, improper feeding, and mishandling of mobility aids. These concerns had reportedly been communicated to supervisory staff but were dismissed or not acted upon. The facility's policies required immediate reporting and investigation of any suspected abuse, as well as protective measures for residents during investigations. However, these procedures were not followed in this case. The NHA and DON were unaware of the abuse allegation until it was brought to their attention by surveyors, and no immediate protective actions were taken for the resident following the initial report. The failure to report and investigate the allegation in accordance with policy resulted in a deficiency at the immediate jeopardy level.
Removal Plan
- DON will do a full head to toe skin assessment on Resident #39, noting any discolorations, bruises, or visible markings on body.
- DON and NHA will place phone call to resident family to inform them of the allegation of abuse and share with them the steps we are taking and findings from skin assessment.
- Alleged perpetrator will not be allowed to return to work until investigation is complete.
- DON will begin investigation into allegation by interviewing staff, residents, and speaking to family members.
- A report with the findings of the investigation will be provided to the State Agency.
- NHA will provide a copy of the Abuse Prohibition Policies and Procedures to all staff currently at facility to review and sign. Copies of this will be provided to all oncoming staff at the start of next shift to be reviewed and signed.
- An all staff Inservice is scheduled to educate staff on the importance of adhering to the Abuse Prohibition Policies and Procedures.
- DON and NHA upon arriving at facility, will read through progress notes for all residents on a daily basis, and immediately investigate any allegation of abuse or neglect. DON and NHA will alternate reading through progress notes on Saturday and Sunday.
- NHA will continue to ensure that all staff are compliant with their mandatory, annual Abuse/Neglect Inservice.
- SSD will conduct spot interviews with residents to ensure residents they feel they are receiving adequate care.