Failure to Report and Investigate Abuse Allegation and Chemical Ingestion
Penalty
Summary
The facility failed to report and investigate an allegation of abuse and an incident of chemical ingestion involving a resident with severe cognitive impairment and a history of trauma. Video footage showed the resident expressing concern about being harmed at night, referencing a bruise and stating that a man was bothering her. The registered nurse present did not further question the resident or initiate an investigation into the possible abuse allegation, nor was there documentation of the incident or any follow-up in the resident's progress notes. Additionally, the same resident was observed on video ingesting wound cleanser, a product labeled to seek medical attention or contact poison control if swallowed. The psychologist present did not recall reporting the ingestion, and there was no documentation that the physician or poison control was notified. Interviews with facility staff, including the nurse practitioner, ADON, and DON, confirmed a lack of awareness and follow-up regarding the ingestion event. The facility's policy requires immediate reporting and investigation of abuse allegations and incidents, but these procedures were not followed in either case.