Failure to Investigate Abuse Allegation and Chemical Ingestion
Penalty
Summary
The facility failed to investigate and respond appropriately to allegations of abuse and chemical ingestion involving a resident with severe cognitive impairment and a history of trauma. The resident, who was dependent on a ventilator and had diagnoses including chronic respiratory failure and paranoid schizophrenia, was observed on video footage making a statement about being harmed by a male at night and later ingesting wound cleanser. Despite these incidents, there was no documentation in the resident's progress notes regarding the abuse allegation or the ingestion event, nor evidence that the physician or poison control were notified. Staff interviews revealed a lack of awareness and follow-up regarding both the abuse allegation and the ingestion of wound cleanser. The psychologist present during the ingestion could not recall reporting the incident, and nursing staff were unaware of both the ingestion and the resident's claim of abuse. The facility's own policy requires immediate reporting and investigation of abuse allegations and injuries of unknown origin, as well as appropriate medical response to chemical ingestion, but these procedures were not followed in this case.