Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prevent abuse, neglect, and theft, as evidenced by multiple incidents involving several residents. In several cases, staff did not communicate allegations of abuse or resident-to-resident altercations to management, did not document the events in the electronic medical record (EMR), and did not notify physicians or families as required. For example, one resident reported being punched by another resident, but there was no immediate documentation, assessment, or notification to the physician or family, and the incident was not investigated until surveyors brought it to the attention of the Administrator and DON. Staff involved in the incident admitted to not reporting or documenting the event, with some stating they did not believe the incident could have occurred due to the alleged perpetrator's physical limitations or the reporting resident's history of similar allegations. In another incident, a resident found a male resident in her bed and reported it to staff, who removed the resident and relocated him. However, there was no documentation of the incident in the involved residents' records, nor evidence of timely notification to families or physicians. Staff interviews revealed inconsistent understanding of reporting and documentation requirements, with some staff unaware of the need to inform management, families, or physicians, and others believing that reporting was unnecessary if they doubted the allegation. The facility's abuse training was found to be inconsistently applied, with some staff only receiving education after being directly involved in an incident, and others not completing required training modules. Additional incidents included a resident entering another resident's room and exposing himself, with no documentation or notification to management, families, or physicians. Interviews with staff and administration confirmed a lack of awareness of these events until prompted by surveyors, and acknowledged the absence of required documentation. The facility's own policies required immediate reporting, thorough investigation, and documentation of all allegations of abuse, neglect, or mistreatment, but these procedures were not followed in multiple cases, resulting in a failure to protect residents and ensure proper communication and documentation.