Failure to Protect Residents and Conduct Thorough Abuse/Neglect Investigations
Penalty
Summary
The facility failed to immediately implement effective protective measures and conduct thorough investigations in response to allegations of abuse and neglect for two residents. In the case of one resident with a right below-knee amputation, moderate cognitive impairment, and chronic pain, a nursing assistant reported witnessing a registered nurse physically and verbally abuse the resident during medication administration. The nursing assistant delayed reporting the incident due to fear of the nurse, and did not take steps to protect the resident from further harm. The alleged perpetrator was not immediately removed from access to the resident, and the resident’s representative was not promptly or thoroughly interviewed as part of the investigation. The investigation was incomplete, with staff interviews failing to corroborate the initial allegation, and the process for resident protection and data collection was not fully followed according to facility policy. For another resident with dementia and degenerative joint disease, the facility failed to thoroughly investigate a series of nine falls, seven of which were unobserved, over a five-month period. The incident reports for these falls lacked witness statements and did not document that abuse or neglect had been thoroughly ruled out as potential causes. The resident’s care plan, which identified a high risk for falls due to multiple medical and cognitive factors, was only updated with additional interventions after two of the nine falls, indicating a lack of comprehensive follow-up and prevention efforts after each incident. Interviews with facility leadership confirmed that investigations into the causes of the falls were not thorough and that limited interventions were implemented to prevent future incidents. The facility’s actions did not align with its own policy, which requires immediate protection of residents and comprehensive investigation of all alleged abuse, neglect, or unexplained injuries. These failures resulted in residents being at risk for unidentified abuse, unmet care needs, and potential continued exposure to abuse or neglect.