Failure to Implement Abuse Policy Following Resident Allegation
Penalty
Summary
The facility failed to implement its abuse policy when a resident with Parkinson's disease, who required significant assistance with daily activities and had intact cognition, made allegations of physical and verbal abuse by a licensed vocational nurse (LVN). The resident reported to both the DON and the administrator that the LVN jabbed him with a needle, causing pain, and hit him in the face while administering medication. The resident also expressed fear of retaliation and discomfort with the LVN continuing to provide care. Despite these reports, the facility did not notify the abuse coordinator, did not initiate an investigation, and allowed the alleged abuser continued access to the resident after the allegations were made. Interviews and record reviews revealed that the DON was informed of the resident's complaints, including pain from an injection and fear of the LVN, but did not complete a thorough assessment, notify the abuse coordinator, or report the incident as required by policy. The administrator, who also served as the abuse coordinator, was made aware of the resident's allegations but did not file a report with the state. Both the DON and administrator acknowledged in interviews that proper reporting and investigation procedures were not followed. The resident was subsequently moved to a different hallway, which he perceived as retaliatory, and the LVN continued to have access to him during this period. The facility's failure to follow its abuse, neglect, and exploitation policy resulted in the lack of timely reporting, investigation, and protection for the resident. The events were substantiated by audio recordings, interviews with the resident, staff, and therapy personnel, and review of facility documentation. These failures placed residents at risk for physical harm and mental anguish, as the required protocols to ensure resident safety and address allegations of abuse were not implemented.