Failure to Report and Investigate Resident Behavioral Incident per Abuse Prevention Policy
Penalty
Summary
Facility staff failed to follow abuse prevention policies regarding the reporting and thorough investigation of a behavioral incident involving a resident. The incident involved a resident with multiple medical diagnoses, including cerebral infarction, diabetes, hypertension, and psychiatric conditions, who was assessed as cognitively intact. On the morning of the incident, the resident became verbally aggressive and made threats toward staff after reporting that he did not receive assistance when requested. The situation escalated to the point where law enforcement was contacted, and an emergency custody order was attempted but not executed. The resident calmed down after police intervention, and no further aggressive behaviors were noted that day. The facility's investigation into the incident included statements from several staff members who witnessed the resident's verbal aggression and threats, which included threats of physical violence and the use of vulgar language. However, the investigation did not include a statement from the certified nurse aide assigned to the resident at the time of the incident, nor did it address the resident's allegation that assistance was not provided or that his rights had been violated. Additionally, there was no documentation of interviews with other residents who may have witnessed or been affected by the incident. Despite the involvement of police and the resident's allegations of mistreatment, the incident was not reported to the state agency or adult protective services as required by the facility's abuse prevention policies. The policies mandate immediate reporting and thorough investigation of all allegations or observations of abuse, neglect, or mistreatment, including communication of findings to appropriate authorities. The failure to report and fully investigate the incident, including all relevant staff and resident interviews, constituted a deficiency in the facility's compliance with its own policies and regulatory requirements.