Failure to Implement Abuse and Neglect Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Facility policy required that all incidents, regardless of severity, be reported promptly, investigated, and documented with witness statements. However, for a resident with a tracheostomy, repeated falls, and a hip fracture, there were multiple reports of neglect, including long waits to be changed and the development of sores. The resident, who was cognitively intact, reported waiting five to six hours to be changed and expressed concerns about staff turning off the call light and not returning for hours. The investigation into the resident's allegations was incomplete, as it failed to identify an alleged perpetrator and did not include witness statements from nursing staff. The only statements obtained were from the DON and Medical Director, both signed by the Nursing Home Administrator. Documentation showed the resident's brief was changed only two to three times a day. The resident continued to report delays in care and expressed fear of retaliation. Facility leadership confirmed that written policies and procedures to prevent abuse, neglect, and exploitation were not properly implemented for this resident.