Inadequate Staff Education and Failure to Investigate or Report Abuse Allegations
Penalty
Summary
The facility failed to provide adequate abuse education to administrative staff, resulting in insufficient knowledge regarding the identification and management of abuse allegations, particularly for residents with cognitive deficits. In one instance, a resident with cognitive impairment was found to have scattered, healing bruises on the lower back, accompanied by pain. Nursing notes indicated no falls or injuries during the relevant period, and no investigation was conducted to determine the cause of the bruising. The administrative staff member responsible for abuse investigations was not notified of the incident and had not completed an investigation at the time of the survey. In another case, a resident became agitated and threatened physical harm to a roommate, ultimately hitting the roommate, though the incident was not witnessed. The event was investigated as abuse, but the allegation was not reported as required. The staff member involved had not received abuse training from the facility, and there was uncertainty regarding the training provided by the staffing agency. Documentation of abuse and neglect training for staff was incomplete, with missing dates and unclear instructor qualifications. The facility's policy required reporting of abuse allegations, but this was not consistently followed.