Failure to Implement Abuse Prevention Policies and Procedures
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, as evidenced by the lack of trauma assessments and abuse prevention care plans for multiple residents with cognitive impairments and behavioral issues. Several residents, including those with significant medical histories such as advanced dementia, stroke, pressure ulcers, and mobility deficits, were not screened for trauma or abuse upon admission, and no individualized abuse prevention care plans were developed for them. In cases where residents reported abuse allegations, the facility did not conduct trauma assessments or update care plans accordingly. Specifically, residents with histories of mental, physical, or sexual abuse allegations did not receive trauma assessments following these incidents. For example, one resident with a history of depression, cognitive deficits, and a stage 4 pressure ulcer reported mental abuse, but no trauma assessment or abuse prevention care plan was completed. Another resident with cognitive impairment and behavioral issues reported a sexual abuse allegation, yet no trauma assessment or care plan was developed. Similar patterns were observed for other residents who either refused trauma assessments upon admission or had abuse allegations without subsequent assessments or care planning. Interviews with facility staff, including the Social Service Director, Administrator, and Memory Care Coordinator, revealed a lack of clarity and consistency regarding the timing and frequency of trauma assessments and the development of abuse prevention care plans. Staff indicated that trauma assessments were only performed upon admission and not after abuse allegations, and there was no process in place to ensure that vulnerable residents with cognitive or behavioral issues were care planned for abuse prevention. Review of facility policies confirmed that resident screening for abuse and neglect was not adequately addressed.