Failure to Investigate, Report, and Protect After Abuse Allegation
Penalty
Summary
The facility failed to immediately investigate, report, and protect a resident following allegations of abuse and neglect by a licensed vocational nurse (LVN). The resident, a 51-year-old male with Parkinson's disease and other medical conditions, reported being stabbed in the arm with an insulin needle and scratched on the nose by the LVN. He also described being hit in the face when receiving medication and expressed fear and discomfort regarding the LVN's care. Despite these reports, the facility did not promptly initiate an investigation or remove the LVN from providing care to the resident. Interviews and record reviews revealed that the resident communicated his concerns to both the DON and the administrator, including his fear of retaliation and his desire for the issue to be handled discreetly. The DON acknowledged being informed of the resident's pain and discomfort after an injection but did not conduct a thorough assessment, notify the abuse coordinator, or report the incident as required. The administrator, who also served as the abuse coordinator, was not immediately informed of the allegations and did not file a report with the state upon learning of the situation. The LVN continued to provide care to the resident after the initial report, and the resident was later moved to a different hallway, which he perceived as retaliatory. The facility's own policy required all reports of abuse, neglect, or exploitation to be reported to appropriate agencies and thoroughly investigated, but this was not followed in this case. The failures in immediate investigation, reporting, and protection placed the resident at risk for physical harm and mental anguish. The deficiency was identified as Immediate Jeopardy, and the facility was found out of compliance due to the lack of effective corrective systems at the time of the incident.