Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse for one resident who reported that several nurses had been rough while repositioning, resulting in bruising on the left arm and inner elbow. The resident, who had diagnoses including intervertebral disc degeneration, morbid obesity, and long-term opiate use, could not recall the exact date of the incident but reported the event to a nurse, who documented the complaint in the progress notes. Despite this documentation, there was no evidence that an investigation was initiated or that the required notifications to the Director of Nursing (DON) or Administrator were made at the time of the allegation. Interviews with nursing staff revealed that the standard procedure for abuse allegations included immediate reporting to the Administrator and DON, conducting interviews with involved staff and residents, performing a head-to-toe skin assessment, and documenting all actions taken. However, the nurse who received the complaint did not initiate an investigation, citing uncertainty about which staff were involved due to the resident's inability to specify the date. The DON and Administrator both confirmed they were not informed of the allegation and that no investigation or follow-up was conducted as required by facility policy. The facility's abuse policy required immediate notification of the DON and Administrator for any suspected or reported abuse, initiation of an investigation, and completion of a written summary of findings. In this case, the lack of communication and failure to follow established procedures resulted in the absence of an investigation into the resident's allegation of physical abuse, as well as a lack of documentation regarding any follow-up or actions taken to ensure the resident's safety.