Failure to Implement Abuse and Neglect Policies and Procedures
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect prevention for two residents. One resident reported waiting two hours for assistance, after which a staff member entered her room, acted disgusted, and provided care in a rough manner, causing the resident pain and distress. Documentation showed that the incident was not thoroughly investigated, as required by facility policy. There was no evidence of interviews with the resident or staff, nor was the incident reported to the state agency, despite the policy stating that any suspicion or allegation of abuse warrants immediate investigation and reporting. Another resident, with moderate cognitive impairment and multiple medical diagnoses, reported that a staff member was rude to her and also described a verbal altercation with a roommate that made her feel unsafe. The facility's documentation of these incidents was minimal, with only brief notes indicating that the resident was moved or that the staff member received verbal education. There was no evidence of a comprehensive investigation, interviews with involved parties, or reporting to the state agency as outlined in the facility's abuse and neglect protocol. In both cases, the administrator determined that the incidents did not meet the criteria for abuse and therefore did not initiate a full investigation or report the allegations. The facility's actions did not align with its own policies, which require thorough investigation and timely reporting of all allegations or suspicions of abuse, neglect, or exploitation. The lack of proper documentation and follow-up demonstrates a failure to protect residents and ensure compliance with regulatory requirements.