Failure to Protect Residents and Incomplete Abuse Investigations
Penalty
Summary
The facility failed to immediately implement protective measures following an allegation of staff-to-resident verbal abuse. In one instance, a resident with moderate cognitive impairment reported to a nurse that two CNAs spoke to them in a derogatory manner and delayed pain medication administration. The nurse did not report the allegation immediately, and the CNAs completed their shift before the incident was reported to the Administrator and DON. The facility's policy required immediate suspension of the alleged perpetrators, but this did not occur until after the shift had ended, leaving the resident potentially unprotected during that time. Additionally, the facility did not thoroughly document or conduct comprehensive investigations into allegations of abuse or neglect for two other residents. In one case, a resident and their family member alleged verbal abuse by a CNA. The facility's investigation file lacked documented interviews with all relevant staff, including another CNA who worked with the alleged perpetrator, the assigned RN, and the family member who made the allegation. The Administrator acknowledged that interviews may have occurred but were not documented, resulting in an incomplete investigation record. In another case, a resident was found with unexplained bruising on their hand and wrist. Although the resident attributed the bruising to staff assisting them, the facility's investigation did not include a root cause analysis or specific questioning of staff about how the resident was transferred or repositioned. The investigation focused on whether abuse occurred but did not address whether improper transfer techniques may have caused the injury. The family member of the resident was not informed of the outcome of the investigation, and the Administrator later admitted that the investigation should have included an assessment of staff transfer practices.