Failure to Follow Abuse Prevention and Investigation Policies
Penalty
Summary
Facility staff failed to follow established abuse prevention policies in two separate incidents involving residents. In the first case, a resident with a history of traumatic brain injury, epilepsy, dementia, and substance abuse tested positive for marijuana and methamphetamine after being sent to the emergency room for seizure-like activity. Prior to this, staff had noted unusual behavior, a chemical smell in the room, and the discovery of drug paraphernalia and prohibited items in the roommate's possession. Despite these findings and the positive drug test, the facility did not report the incident to the state agency, adult protective services, or law enforcement, nor did they conduct a documented investigation into the resident's positive drug test as required by facility policy. The facility's own policies mandate immediate review, investigation, and reporting of all allegations or observations of abuse, neglect, or exploitation, including injuries of unknown origin and misappropriation of property. These policies also require written reports to be submitted to appropriate agencies and individuals within specified timeframes. However, in this instance, the administrator did not initiate a formal facility reported incident (FRI) regarding the drug findings, focusing instead on the roommate's aggressive behaviors. The only FRI submitted pertained to the roommate's verbal aggression and subsequent transfer, with no mention of the drug-related findings or the affected resident's positive drug test. In a separate incident, the facility did not fully implement its abuse policy regarding documentation of a resident-to-resident altercation. An investigation into inappropriate touching by one resident toward three others was missing required written witness statements. The director of nursing was unable to locate these statements, and interviews with staff revealed that at least one witness did not recall providing a statement. Facility policy specifically requires that witness reports be obtained in writing, signed, and dated, but this was not completed or documented in the investigation.