Failure to Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse and Neglect policy by not ensuring that an allegation of staff-to-resident abuse was reported and investigated in a timely manner. A resident with Parkinson's Disease, chronic pain, and anxiety disorder, who was non-ambulatory and required assistance with transfers and activities of daily living, was found to have swelling and pain in the fingers, later determined to be a questionable fracture. The resident reported to staff that a CNA had been rough during care, and this concern was communicated to both a nurse and the ADON. However, neither the nurse nor the ADON reported the allegation to the Administrator or the DON as required by policy, nor did they document the incident or conduct a thorough assessment at the time of the complaint. Despite the resident's complaint of rough handling and subsequent injury, the incident was not treated as a potential abuse allegation. The staff initially attributed the injury to a possible gout flare, and only after further medical evaluation was a fracture suspected. The resident's statements about being hurt by a staff member were not immediately investigated, and the required Incident & Accident report was not completed. The Administrator and DON were not made aware of the allegation until much later, after which the investigation and reporting process began. Interviews with staff revealed confusion and lack of clarity regarding the reporting process for abuse allegations. The ADON and RN involved could not recall if the incident was reported to the appropriate administrative personnel, and there was no documentation of the resident's complaint or assessment following the allegation. The facility's failure to follow its own policy resulted in a delay in recognizing, investigating, and reporting a potential abuse incident involving a resident.