Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent and respond to abuse, neglect, and misappropriation of resident property. In one incident, a certified nursing assistant (CNA) was instructed to physically restrain a resident while another CNA administered medication, which involved holding the resident's arms and face and forcibly giving medication. This incident was not immediately reported to the Director of Nursing (DON) or the Nursing Home Administrator, and the accused staff continued to work in the facility for several days after the incident before it was reported. The facility did not submit a required facility-reported incident to the state agency for two separate abuse allegations, nor did it report the abuse to law enforcement or notify the resident's representative. Additionally, a full investigation into the allegations of abuse for two residents was not completed, and there was a lack of documentation regarding notification of the resident's representative. The report also details that staff education on abuse, neglect, mistreatment, and misappropriation of resident property was not consistently completed upon hire or annually. One CNA did not have recorded abuse education training, and the system for ensuring all staff received required training was inadequate, relying only on nurse clinical coordinators to monitor completion. Signed memorandums for re-education after the incident did not include all staff signatures and did not cover the full scope of the abuse policy, such as ensuring resident safety, reporting to state agencies, and law enforcement notification. The DON acknowledged that some staff had lapses in annual training and that a new system for tracking training was still being developed. In another incident, law enforcement was contacted by a resident's family member regarding an allegation of abuse. Although law enforcement visited the facility, the facility did not submit a facility-reported incident to the state agency. The DON stated that the allegation was not reported or investigated because it was believed to be unfounded due to previous similar reports. The facility's failure to report, investigate, and document these incidents, as well as to ensure staff were properly trained, represents a breakdown in the implementation of its abuse prevention policies and procedures.