Failure to Implement Abuse Reporting and Protection Procedures
Penalty
Summary
The facility failed to follow and implement its abuse policy and procedures in two separate cases involving residents with cognitive impairments. In the first case, a resident with severe dementia was struck on the arm by a nursing assistant during care. Another nursing assistant witnessed the incident but did not immediately intervene or report the abuse to the on-duty nurse or administrator. Instead, the witness left the facility at the end of her shift and only reported the incident to the DON after arriving home. As a result, the accused staff member continued to work on the floor with access to other residents until the DON was notified and took action to remove her from the building. The incident was not reported immediately as required by facility policy, and the initial response was delayed. In the second case, an allegation of staff-to-resident abuse was reported to Adult Protective Services (APS) by a resident's roommate. The APS social worker visited the facility to investigate, but the facility's social worker and unit manager did not document or report the allegation to the administrator, state agency, or law enforcement as required. The administrator and DON were unaware of the allegation and the APS investigation until months later, when a letter from APS was found in the social worker's desk. There was no record of the incident in the facility's reportable incidents log, and the required internal investigation and notifications were not completed. Both cases demonstrate failures in immediate reporting, protection of residents, and adherence to established abuse policies. Staff did not follow procedures for timely intervention, reporting, and investigation, resulting in lapses in resident protection and regulatory compliance.