Failure to Immediately Protect Resident and Report Abuse Allegation
Penalty
Summary
The facility failed to develop and implement effective abuse prevention policies and procedures, specifically lacking clear direction for staff on how to immediately protect residents following an abuse allegation. The written abuse policy did not instruct staff to remove alleged perpetrators from resident access after an allegation was made. Additionally, the policy was not effectively implemented in the areas of timely reporting and staff training, as evidenced by staff not being aware of or following the correct reporting process. An incident occurred involving a cognitively intact resident who alleged that night shift nursing assistants were rough and spoke harshly to her during incontinence care. The resident reported feeling abused and later showed a bruise to her left lower abdomen, which she attributed to the care provided by the staff. Multiple staff members, including nursing assistants and unit managers, were involved in the incident and subsequent reporting. However, none of the staff immediately notified the Administrator of the abuse allegation, and the alleged perpetrators were not promptly removed from resident care duties. Staff interviews revealed confusion about reporting responsibilities, with some assuming others had reported the incident or were unaware of the need to escalate the allegation. The delay in reporting resulted in the Administrator not being informed of the abuse allegation until more than 24 hours after the incident. During this time, at least one of the alleged perpetrators remained in the facility and was scheduled to work additional shifts. Staff involved in supervisory roles indicated they had not received adequate training on the reporting process for abuse allegations. The facility's failure to ensure immediate protection of residents and timely reporting of abuse allegations constituted a deficiency in both policy development and implementation.