Failure to Investigate and Report Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse involving a resident who required assistance with transfers and had intact cognition. In both cases, there was no evidence that a resident statement, accused staff statement, assessment of the resident, bedside staff interviews, or a police report were completed. The facility also did not document a body audit or a nurse assessment in the medical record following the allegations. The incidents were not reported to the appropriate authorities or the State Agency/Office of Long Term Care (OLTC) as required by facility policy and state regulations. When the first allegation was made that a staff member was rough with the resident, the staff member was simply reassigned to another hallway and allowed to continue working with other residents. The incident was reported to the Assistant Director of Nursing (ADON), but no formal investigation or documentation was completed at that time. The ADON did not conduct a body audit or assessment and did not know if the allegation was investigated further. The Certified Nursing Assistant (CNA) Supervisor also failed to report a separate incident involving another staff member and did not complete any write-up or formal report, only moving the accused staff member to a different hall. The Administrator later provided a minimal two-page investigation that lacked essential elements such as resident and staff interviews, body audits, and proper documentation. The Administrator admitted that the incident was not reported to mandatory authorities and that the documentation provided was the entirety of the investigation. The facility did not have an abuse coordinator at the time, and the highest-ranking person present was responsible for investigations. The Director of Nursing (DON) confirmed that the accused staff should have been separated from residents and that the incident should have been reported and investigated immediately.
Removal Plan
- Provide in-service training for all staff on reporting abuse and neglect to the Administrator, the DON, and Office of Long-Term Care.
- Report all incidents properly.
- Ensure resident safety.
- Interview residents regarding abuse and conduct body audits for residents unable to verbalize abuse.
- Appoint the DON to monitor, investigate, and report allegations of abuse.
- Implement a monitoring tool for documenting and reporting allegations of abuse.
- Appoint the DON as the Abuse and Neglect Coordinator.
- Ensure all staff complete training on reporting of abuse before returning to work.