Failure to Protect Residents from Abuse and Inadequate Reporting of Allegations
Penalty
Summary
The facility failed to protect residents from abuse and did not follow its own policies regarding the reporting and investigation of abuse allegations. In one incident, a resident with quadriplegia and profound intellectual disabilities, who was non-verbal and completely dependent on staff, was found by a CNA being touched on the face by another resident who was masturbating at the bedside. The non-verbal resident was observed trying to cry and move his head away, indicating distress. Staff immediately separated the residents and reported the incident to an LPN, who, along with the CNA, documented the event. However, the Administrator, after being notified, did not report the incident to the State Survey Agency or initiate a facility investigation, as required by policy, and did not consider the event to meet the threshold for reporting. The care plan for the resident exhibiting sexual behaviors lacked interventions for such behaviors prior to the incident. In another case, a cognitively intact resident alleged verbal abuse and withholding of pain medication by an LPN. Multiple staff statements corroborated that there was a loud verbal altercation between the resident and the LPN, during which profanities were used and the LPN stated the resident would not receive pain medication. The resident reported only receiving pain medication once and experiencing significant pain. Staff interviews confirmed that the LPN and the resident exchanged raised voices and profanities, and the LPN walked out of the room after the altercation. The Administrator was not informed of the incident immediately, contrary to facility policy. The facility's policy requires immediate reporting and investigation of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including those involving resident-to-resident abuse and staff-to-resident abuse. The policy also specifies that steps must be taken to protect residents after a report of possible abuse and that all incidents must be reported to the Administrator and State Survey Agency within specified timeframes. In both incidents, the facility failed to follow these procedures, as neither incident was reported to the appropriate authorities nor was a timely investigation initiated.