Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident. Specifically, a resident with moderately impaired cognition and significant physical limitations reported that a CNA yelled at him and made demeaning comments after he had an incontinence episode and requested assistance. The resident stated that the CNA's actions made him feel ashamed and scared, and that he reported the incident to another staff member the following day. An LVN working the night of the incident heard loud voices coming from the resident's room and believed it could have been yelling, but did not intervene or report the situation to the abuse coordinator, as required by facility policy. The LVN later acknowledged that she should have acted to ensure the resident's safety. Other staff interviewed were able to correctly identify abuse and the appropriate reporting procedures, but the LVN's failure to report the incident represented a breakdown in the facility's abuse prevention protocol. The facility's policies required all employees to treat residents with kindness, respect, and dignity, and to report any suspected abuse or neglect immediately to the abuse coordinator. Despite these policies, the failure to report and address the incident in a timely manner constituted noncompliance with the facility's own procedures for preventing and responding to abuse.