Failure to Investigate and Protect After Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of potential verbal and physical abuse was thoroughly investigated and that protection was provided to a resident after the alleged incident. The incident involved a nursing assistant (NA) who was reported to have handled a resident roughly and made verbally aggressive remarks. The resident, who was severely cognitively impaired, nonverbal, and dependent on staff for activities of daily living, was agitated during care and attempted to bite the NA. In response, the NA reportedly held the resident's arm to his mouth and told him to bite himself. The incident was witnessed by another NA, who documented the rough handling and verbal abuse, but there was a delay in reporting the incident to the director of nursing (DON) and administration. Despite the facility's policy requiring immediate suspension of staff accused of abuse and prompt initiation of an investigation, the alleged perpetrator continued to work with residents after the incident. Documentation and interviews revealed that the incident was not immediately reported to the DON or administrator, and the staff involved were not promptly removed from resident care. Additionally, there was a lack of documentation in the resident's progress notes regarding the alleged abuse, investigation updates, or communication with the resident's representative and provider. Staff interviews indicated that several employees were unaware of the abuse allegation and had not received any recent abuse education related to the incident. The facility's investigation was incomplete, lacking key elements such as incident reports, comprehensive staff and resident interviews, and evidence of education on abuse procedures. The social services designee reported limited involvement in the investigation and was not provided with sufficient information to ensure resident safety and well-being. The administrator and DON acknowledged that the expected interventions, including immediate removal of the alleged perpetrator and timely initiation of the investigation, did not occur as required by facility policy.