Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure by not investigating an allegation of abuse involving a resident with severe cognitive impairment and significant assistance needs for activities of daily living. The resident's family member reported to staff that a CNA was rough while changing the resident's incontinent pad and provided a photo of the CNA involved. The family member stated they informed facility staff of the incident. Despite this, the Assistant Director of Nursing (ADON) did not report or investigate the allegation, stating that the resident said she was fine. Other staff, including a CNA and the Director of Staff Development (DSD), confirmed that being rough with a resident is considered abuse and should be reported and investigated immediately. The Director of Nursing (DON) acknowledged being informed that the resident was changed despite refusing care and agreed that the allegation should have been reported and investigated, but at the time did not consider it abuse. Review of the facility's policies confirmed the requirement to thoroughly investigate all allegations of abuse, including interviewing all involved parties and documenting evidence. The failure to follow these procedures resulted in the facility not investigating the reported incident of rough handling, contrary to its own abuse prevention and reporting policies.