Failure to Implement Abuse and Neglect Prevention Policies Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not ensure that a resident with significant cognitive and physical impairments was protected from neglect, resulting in the resident sustaining serious injuries, including an intracerebral hemorrhage and a closed displaced intertrochanteric fracture of the left femur. The resident had a history of repeated falls, was dependent on staff for all activities of daily living (ADLs), and was assessed as a high fall risk. Despite these known risks, the facility did not provide effective interventions or services to address the resident's care needs. On the day of the incident, the resident, who primarily spoke Spanish and had moderate to severe cognitive impairment, was left unsupervised on the toilet by a CNA who was not familiar with the resident's clinical needs and could not communicate effectively due to the language barrier. The CNA left the resident alone after the resident gestured for privacy, and did not ensure that another staff member was monitoring the resident. The resident subsequently fell in the bathroom, resulting in significant injuries. Interviews revealed that the resident was unable to use the call light due to her cognitive status, and the communication board intended to assist with her needs was not present in her room at the time of the incident. Further review showed that the facility's administrative staff did not promptly investigate or self-report the incident as required. Staff interviews indicated a lack of awareness of the resident's fall risk and care plan interventions, and there was confusion among staff regarding who was responsible for monitoring the resident. The care plan for the resident included the use of a communication board and supervision during toileting, but these interventions were not consistently implemented. The failure to follow established protocols and ensure appropriate supervision directly contributed to the resident's injuries.