Failure to Implement Abuse Identification and Reporting Policy
Penalty
Summary
Facility staff failed to implement the required components of their abuse prohibition policy for a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, sleep apnea, and anxiety. The resident required extensive assistance with daily activities. A medication error occurred involving the administration of an injected medication, which was later determined to be a transcription error. The resident's representative raised multiple concerns about care, including medication administration, behavior management, diabetes management, activities, and provider oversight, during a meeting with facility leadership. Despite these concerns and the facility's policy identifying unauthorized chemical restraints as abuse, staff did not identify or report the incident as potential abuse or neglect to the State Agency. Staff interviews revealed that the concerns expressed by the resident's representative were treated as educational opportunities rather than allegations of abuse or neglect. The Assistant Director of Nursing and the Administrator both confirmed that the incident was not reported to the State Agency, as they did not consider it to be abuse or neglect. The Director of Nursing acknowledged that the administration of psychotropic medications as an injectable could constitute a chemical restraint and a form of abuse, as outlined in facility policy. However, the facility did not follow its own procedures for identification and reporting, resulting in a failure to protect residents from potential abuse and neglect.