Failure to Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of abuse made by a resident with a history of making such claims. The resident, an elderly female with diagnoses including dementia with behavioral disturbance, chronic venous hypertension with ulcers, stage 3 chronic kidney disease, hypothyroidism, and recurrent severe major depressive disorder, was admitted to the facility and had documented behavioral issues. On one occasion, after an incident in the bathroom, the resident stated that she had been abused and expressed a desire to contact a family member. This statement was documented in the behavior progress note, but no abuse investigation report was completed for the allegation. Interviews with facility staff revealed that the administrator and DON were not made aware of the resident's statement, and the nurse involved considered the comment to be a manifestation of the resident's psychiatric behavior rather than a reportable abuse allegation. The facility's policy requires all allegations of abuse, including resident reports, to be immediately reported to the administrator and state authorities. However, in this case, the staff did not follow the required protocol, and the incident was not reported or investigated as an abuse allegation.