Failure to Prevent, Report, and Investigate Resident Abuse and Neglect
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to maintain the highest practicable well-being of residents. Specifically, administration did not ensure residents were free from abuse, neglect, and exploitation, and failed to properly identify, communicate, and consistently implement policies and procedures. The survey found that for two of four residents reviewed, the facility did not protect them from abuse, and for three of eight residents, incidents of resident-to-resident abuse were not reported to the State Agency, law enforcement, or the Administrator as required. Additionally, alleged violations involving abuse, neglect, or mistreatment were not thoroughly investigated for three of eight residents reviewed. Interviews revealed that the Administrator was not always promptly informed of incidents and relied on the DON for updates and investigations. The Administrator stated that reporting of incidents depended on the investigation and witness statements, and they did not feel certain incidents were reportable due to lack of confirmed intimate contact. The facility's QAPI plan did not previously include abuse as a focus area, and the loss of the social worker left unit managers and CNAs to manage residents with inappropriate behaviors. The Administrator acknowledged delays in being informed of incidents and described the investigation process as involving staff interviews, resident assessments, and implementation of interventions based on findings.