Failure to Implement Abuse Reporting and Investigation Policy
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse, reporting, and investigations for a resident who alleged physical abuse by staff. The resident, who had diagnoses including Parkinsonism, muscle wasting, quadriplegia, and depression, reported to the Administrator that staff physically fought with her during a care episode. The resident had the capacity to understand and make decisions, and her assessment indicated she could communicate her needs. On the day of the incident, the resident expressed not wanting care from a specific CNA and requested to wait for the next shift, but her request was not honored. Instead, two staff members proceeded to provide care, during which the resident became upset and described the interaction as being grabbed against her will, which she characterized as abuse. The resident communicated the incident to the Administrator via text message shortly after it occurred, stating that staff had physically fought with her and did not respect her wishes. The only response from the Administrator was to ask if the incident had been reported to the charge nurse, and no further action was taken at that time. The resident also informed the oncoming nurse but did not receive a follow-up. Interviews with staff confirmed that the incident was not reported to the required agencies within the mandated two-hour timeframe, and no immediate investigation was initiated. The facility's policy required immediate reporting and suspension of accused employees, but these steps were not followed. Further interviews with staff, including the Director of Staff Development and the Administrator, confirmed that the incident met the facility's definition of abuse and should have triggered an immediate investigation and reporting to outside agencies. However, the Administrator acknowledged that no investigation was conducted, and the required notifications were not made. The failure to act according to policy resulted in a delayed investigation of the alleged abuse and left the resident at risk for further harm.