Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its abuse prohibition and prevention policies for multiple residents, as evidenced by the lack of proper reporting and incomplete investigations into allegations of abuse, neglect, and injuries of unknown origin. In several cases, allegations made by residents or their representatives were not reported to required external agencies such as law enforcement and the ombudsman, despite facility policy mandating such notifications. For example, allegations involving rough care, physical abuse, and neglect were not communicated to the appropriate authorities, and documentation showed that notifications were either delayed or not made at all. Investigations into reported incidents were incomplete and did not follow facility policy. In multiple instances, investigation reports lacked statements from the residents who made the allegations, the staff members involved, and potential witnesses. For example, in one case, a resident alleged rough care by a GNA, but the investigation file did not include statements from the resident or the staff present during the incident. Similarly, another resident alleged that a housekeeper pushed them, but the investigation lacked statements from both the resident and the housekeeper, and there was no evidence that other residents or staff were interviewed as required by policy. Interviews with facility leadership confirmed that the expected procedures for thorough investigations and reporting were not followed. The Regional Director of Operations and the Regional Nurse Consultant acknowledged that interviews with all involved parties and timely notifications to external agencies were part of facility protocol, yet these steps were not consistently documented or performed. Additionally, review of initial reports for several other residents revealed that allegations of verbal abuse and injuries of unknown origin were not reported to required agencies, further demonstrating a pattern of noncompliance with abuse prevention and reporting policies.