Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment. The resident was sent to the hospital after a combative episode, where they reported to hospital staff that they had been hit and punched by facility staff. Hospital staff documented two small bruises on the resident, one under the left eye and one on the back. Upon readmission, a nurse and wound nurse noted a healing bruise near the left eye and another on the chest. A physician's progress note documented that during a telehealth visit, the resident alleged being punched and kicked by a black male staff member after requesting medication for a migraine. The facility's policy requires immediate investigation of any abuse allegations, including those reported by residents or documented as physical marks. However, the DON and NHA were unaware of the abuse allegation until the surveyor brought it to their attention, despite the allegation being documented in the physician's note. The DON acknowledged that the clinical team is responsible for reviewing physician notes and that the note containing the allegation was missed during the 24-hour look-back review process. Interviews with facility leadership revealed that no investigation was initiated because the team did not recognize the abuse allegation in the physician's documentation. The resident confirmed to the surveyor that they had not been followed up with regarding the abuse allegation. At the time of the survey exit, the facility had not produced any evidence of an investigation into the reported abuse, despite the requirement to do so per facility policy.