Failure to Thoroughly Investigate Alleged Abuse and Unexplained Injury
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated for one resident. The resident, who had a history of spinal surgery, diabetes mellitus, and morbid obesity, reported experiencing verbal and physical abuse, including being held down by five staff members during a Foley catheter insertion. The resident was cognitively intact and able to communicate effectively. The allegation was reported to a registered nurse three days after the incident, who then notified the Director of Nursing and Director of Social Work, initiating an investigation and reporting the incident to the state health department as required. However, the investigation did not address the presence of a bruise of unknown origin on the resident's upper left arm until two days after the investigation began. Additionally, the investigation did not explore why the LPN involved did not seek assistance from the RN Supervisor or why neither nurse reported the incident to the Director of Nursing at the time it occurred. The facility's abuse prevention policy did not include procedures for conducting investigations after an allegation was made, contributing to the incomplete investigation.