Failure to Investigate and Report Potential Abuse Incident
Penalty
Summary
The facility failed to identify and investigate a potential abuse incident involving a resident who was severely cognitively impaired, dependent on staff for all care, and diagnosed with dementia. The resident was found with bruises in the shape of fingers on both arms and a significant skin tear on the left arm. Staff interviews revealed that a CNA admitted to grabbing the resident's arms during care, which was reported to a licensed nurse and the resident care manager. Despite this, there was no documentation of a thorough assessment, injury report, or investigation into the cause of the injuries, as required by both state guidelines and the facility's own abuse prevention policy. Review of the resident's records showed no adequate description or measurement of the injuries, and the incident was not logged in the facility's incident and accident log. The administrator confirmed that the required steps, including reporting to the administrator, DON, and state agency, were not taken. The facility's failure to follow its abuse prohibition and prevention policy, as well as state reporting guidelines, resulted in a lack of protection for the resident and potentially others from further abuse or neglect.