Failure to Investigate Possible Abuse and Neglect Incidents
Penalty
Summary
The facility failed to implement its policies and procedures to investigate possible abuse and/or neglect for three residents. For one resident with spinal stenosis, heart failure, and osteoarthritis, who required two-person Hoyer lift transfers, there was an incident where the resident's leg was injured during a transfer. The resident reported that staff did not follow her instructions, did not seek nursing assistance when requested, and did not report the incident to a nurse or supervisor. The Director of Nursing later documented conflicting accounts and determined no further investigation or reporting was necessary, and no additional information was provided when requested. Another resident with COPD, muscle weakness, and a history of falls, also requiring two-person transfers, experienced a skin tear during a transfer when an agency CNA attempted to transfer her alone. The incident report noted the incorrect level of assistance was used, but no further investigation was conducted to determine if staff were aware of proper transfer procedures. A third resident with dementia and a history of wandering was found with two large bruises of unknown origin on her arm. The facility's investigation included statements from only a few staff, some of whom were not assigned to the resident during the relevant period, and failed to interview all staff who had provided care in the 72 hours prior to the injury. The Director of Nursing confirmed that the investigation was incomplete and that the facility did not follow its own policies and procedures for investigating possible abuse or neglect.