Failure to Implement Abuse Prevention Program Policy
Penalty
Summary
The facility failed to implement its abuse prevention program policy for all four residents reviewed. According to facility policy, an abuse/trauma assessment is to be completed upon admission, quarterly, annually, and as needed following any allegation or incident of abuse. If a resident scores above 2 on the assessment, an abuse prevention care plan should be initiated and updated after any investigation of abuse or resident-to-resident altercation. However, multiple instances were identified where these procedures were not followed. For one resident, an abuse/trauma assessment indicated a score of 8 after a physical altercation, but the abuse prevention care plan was not updated as required. Another resident had assessment scores of 4 and 9, both indicating risk, yet no abuse prevention care plan was initiated or updated after a resident-to-resident altercation. A third resident had assessment scores of 6 and 9, but again, no care plan was initiated or updated following a physical altercation. In the case of a fourth resident, an assessment score of 3 indicated risk, but no care plan was formulated, and after an allegation of verbal abuse, neither a new assessment nor an updated care plan was completed. Interviews with facility staff confirmed that the responsible personnel were aware of the policy requirements but did not consistently implement them. The facility's policy clearly outlines the need for ongoing assessment and care planning for residents at risk of abuse, but these steps were not taken in the reviewed cases, resulting in a failure to follow established procedures for abuse prevention and care planning.