Failure to Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and a history of repeated falls. The resident, who had minimal cognitive impairment and required assistance with activities of daily living, was sent to the hospital following a fall with injuries. While at the hospital, the resident reported being forced out of a chair by facility staff, resulting in a fall that caused two rib fractures, a right humerus fracture, and right axillary artery damage. This information was documented in the hospital records and subsequently uploaded to the resident's electronic medical record. Despite the hospital documentation and the facility's policy requiring investigation of all suspected abuse allegations, the facility did not conduct an investigation into the resident's claim of staff-to-resident physical abuse. Interviews with the Administrator and DON confirmed that they were unaware of the abuse allegation and had not initiated an investigation. The hospital records, which contained the resident's allegation, were uploaded by an offsite staff member, and the facility leadership did not review or act upon this information.