Failure to Timely Investigate and Protect Residents During Abuse Allegation
Penalty
Summary
The facility failed to promptly initiate an investigation into an allegation of abuse and did not take immediate steps to protect residents during the investigation process. A resident with right-sided hemiplegia and hemiparesis, who was cognitively intact and required staff assistance with activities of daily living, reported that staff had been rough with her during a transfer, resulting in discolored markings on her left forearm. The resident stated she reported the incident to staff the following day. Multiple staff members, including CNAs, LPNs, and RNs, were made aware of the resident's complaint and observed the markings, but the facility did not report the allegation to the state agency or initiate an investigation until several days later, after being prompted by a surveyor. Despite the facility's policy requiring timely investigation and reporting of injuries of unknown origin and alleged mistreatment, the alleged perpetrator was not suspended from resident care until after the survey began. The Director of Nursing was not aware of the allegation until it was brought to administration by the surveyor. The delay in reporting and failure to protect residents during the investigation were confirmed by interviews with staff and administration, and the facility did not follow its own policy for handling such allegations.