Failure to Implement Abuse and Neglect Investigation Policies
Penalty
Summary
The facility failed to implement its policy regarding the thorough investigation of abuse and neglect allegations and did not adequately protect residents from further abuse in two separate cases. In the first case, a resident with hypotension, chronic kidney disease, and nocturia was the subject of a neglect allegation involving a CNA who reportedly told the resident not to use the call light for at least an hour. The facility's self-report lacked details about the incident and the alleged perpetrator, and there was no documentation in the clinical record regarding the incident, assessment, or required notifications. The subsequent investigation did not include interviews with other residents or staff, lacked witness statements, and failed to specify when interviews were conducted or who the witnesses were. The investigation concluded no neglect occurred, but the CNA involved had a documented history of poor performance and was later terminated for a separate incident. In the second case, a resident with monoplegia, chronic heart failure, and depression was involved in an incident of alleged verbal abuse by a family member. The facility's self-report did not indicate whether the family member was separated from the resident during the investigation. While progress notes showed the resident was separated from the spouse and the incident was reported to the physician, administrator, and DON, there was no documentation of follow-up regarding the resident's interaction with the spouse or any limitations on visitation. The investigation report did not include interviews with the alleged perpetrator or potential witnesses, and summaries of interviews lacked details about timing and witness identity. Staff interviews revealed an understanding of the importance of following policies to ensure resident safety and thorough investigations, but staff were unfamiliar with the specific incidents. The facility's policy required immediate suspension of alleged employee perpetrators and interviews with a minimum of three residents to identify trends, but these steps were not consistently documented or followed in the cases reviewed.