Failure to Investigate Allegations of Exploitation and Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of potential exploitation and abuse involving two residents. For the first resident, who had dementia and a history of falls and was severely cognitively impaired, concerns about possible financial exploitation by a family member were known to the Administrator as early as June. Despite repeated attempts by staff to contact the responsible party and ongoing concerns about the resident's assets, no investigation was initiated until surveyors requested information in September. The facility's own policy required prompt and comprehensive investigation of such allegations, but this was not followed. In the second case, another resident with dementia, cerebral ischemia, and COPD, and who was also severely cognitively impaired, was found with bruising and discoloration to the right hand after an incident involving a CNA. The progress notes indicated that the resident had refused care and allegedly swung a backscratcher at the CNA, after which the CNA removed the object from the resident's hand. The facility's investigation into the injury did not include interviews with staff present during the incident, as required by policy, to determine whether abuse had occurred. Interviews with facility leadership confirmed that the required investigations were not conducted in either case. The President of Clinical and the Regional Nurse Consultant acknowledged that both the potential financial exploitation and the injury of unknown origin should have been thoroughly investigated according to facility policy, but this did not occur until prompted by surveyors.