Failure to Implement Abuse Investigation Policies and Procedures
Penalty
Summary
The facility failed to implement its abuse investigation policies and procedures for four of ten sampled residents. In one case, a resident alleged that a mental health worker (MHW) choked and assaulted him, resulting in visible injuries such as bruising and scratches on the face and neck. Despite the allegation and physical evidence, the MHW was not immediately removed from duty, and no investigation was conducted. Other residents who witnessed the incident were not interviewed, and the DON dismissed the allegation as false without following the required investigative process. Another resident reported that a staff member mocked his stutter and that other staff called him derogatory names. The DON acknowledged the allegation but did not initiate an investigation or report the incident within the required two-hour timeframe. The facility later submitted a report, but it was acknowledged as late by the Administrator and DON. Additionally, two residents were involved in two separate physical altercations, with one resident sustaining visible injuries. The facility failed to conduct a thorough investigation after the first incident, did not report the initial allegation, and did not separate the residents until after the second incident. Interviews revealed that staff and residents were aware of the altercations, but appropriate actions to ensure safety and compliance with policy were not taken. The DON and Administrator acknowledged these failures during interviews.