Failure to Implement Abuse and Neglect Prevention Policies Resulting in Resident Injury
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation, specifically by not ensuring a complete and thorough investigation of a potential neglect incident involving a resident. The facility's policy requires procedures for screening, training, prevention, identification, investigation, protection, reporting/response, and corrective action to protect residents from abuse, neglect, and exploitation. However, documentation and staff interviews revealed that these procedures were not fully followed in the case reviewed. A resident with diagnoses including arthritis, Parkinson's disease, and depression was assessed as requiring assistance from two staff members for transfers and was identified as a high fall risk. The care plan specified that the resident needed prompt assistance and that the call light should be within reach. Despite these requirements, the resident was left unattended in the bathroom after requesting privacy, with the call bell placed in her hand. Staff left to respond to another resident's alarm, and the resident subsequently fell, sustaining a dislocated right elbow, fractures of the distal radius, and the coronoid process of the ulna. The incident was not investigated in accordance with the facility's policy, which mandates a thorough internal investigation using incident reports, interviews, and documentation of injuries. The DON confirmed that the resident was left unattended, resulting in the fall and injuries, and acknowledged that the facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of the incident.