Failure to Implement and Follow Abuse Prevention and Investigation Policies
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse by not implementing and following written policies and procedures for abuse prevention and investigation. A resident reported multiple instances of abuse by another resident, including being hit with a wheelchair and inappropriate touching, to several staff members. Despite these reports, staff did not take the complaint seriously, with one nursing assistant making inappropriate comments and failing to report the allegation as required by policy. The resident also attempted to file a formal grievance with the assistance of a representative, but staff, including the Guest Services Director and Social Worker, did not act promptly or appropriately to investigate or escalate the complaint. Interviews revealed that the resident's allegations were not properly documented or investigated, and that key witnesses were not interviewed in a timely manner. The Director of Nursing and Administrator were made aware of the incident but determined it was not reportable, and no written witness statements were collected. Another resident who witnessed the incident confirmed the inappropriate behavior and stated that similar incidents had occurred previously, sometimes involving staff as targets. This witness also reported that no one had interviewed him about the incident prior to the state surveyor's inquiry. The facility's posted policies and procedures, as well as the Elder Justice Act requirements, mandate immediate reporting and thorough investigation of abuse allegations. However, staff failed to follow these protocols, resulting in a lack of timely reporting to appropriate authorities and insufficient protection and support for the affected resident. The failure to implement and adhere to abuse prevention and investigation policies created a situation where residents were not adequately protected from abuse.