Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder, overactive bladder, and a history of cancer. The resident, who was dependent on staff for toileting, alleged that staff made threatening and inappropriate comments during a breakfast incident. The care plan for the resident included interventions for behavior management and a specific protocol for investigating abuse allegations, including checking for physical marks, interviewing assigned staff, and notifying the abuse care coordinator immediately. On the date of the incident, the resident accused staff of making a threatening statement, which was reported to the nurse by the Activity Director. The nurse notified the Administrator and DON, and statements were taken from several staff members present. However, the Administrator did not obtain a statement from the resident at the time of the incident and did not report the allegation to the Department of Public Health as required. The investigation was limited to staff interviews, and the staff members involved were not suspended during the investigation. The Director of Nursing was not aware of the allegation until much later, and there was confusion among staff regarding the resident's toileting schedule and care plan interventions. Documentation shows that the facility's abuse prevention and reporting policy required a thorough investigation of all allegations, including interviews with the person reporting the incident, the resident if interviewable, and review of all relevant documentation. Despite this, the facility did not follow its own protocol, as the investigation was incomplete and not timely, and the required notifications were not made. The failure to properly investigate and report the abuse allegation constituted a deficiency in the facility's response to alleged violations.