Failure to Follow Abuse Policy and Reporting Procedures
Penalty
Summary
The facility failed to follow its abuse prevention policy in two separate incidents involving residents. In the first case, a resident with multiple medical conditions, including vascular dementia and an above-the-knee amputation, was involved in a verbal altercation with a CNA. Another CNA witnessed the staff member yelling, pointing, and making threatening comments toward the resident, which was reported as verbal abuse. The incident was reported by the witnessing CNA to the Unit Manager Nurse (UMN) by phone and via a written report, but the UMN did not escalate the report to the Director of Nursing (DON) or the Administrator. The written report could not be located, and neither the DON nor the Administrator were aware of the incident until informed by surveyors. Despite the facility's policy requiring immediate removal of accused staff pending investigation, the CNA continued to work scheduled shifts after the allegation was reported to the UMN. In the second incident, another resident, who was cognitively intact and dependent for several activities of daily living, sustained a serious injury while being transported by an outside service. The resident fell from her wheelchair during transport, resulting in multiple leg fractures that required surgery. The DON was notified by the hospital of the injury and received hospital records indicating a motor vehicle accident. However, the DON did not conduct a thorough investigation, did not obtain a police report, and did not report the incident as potential abuse or follow the facility's abuse policy regarding injuries of unknown origin. Both incidents demonstrate a failure to adhere to the facility's written policy on abuse, neglect, exploitation, and misappropriation of resident property. The policy requires immediate reporting of all allegations and injuries of unknown source to the state agency, removal of accused staff from duty, and a thorough investigation within five working days. In both cases, these procedures were not followed, resulting in deficiencies related to the facility's handling of abuse allegations and injuries of unknown origin.