Failure to Implement Abuse Investigation Procedures
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the investigation of abuse for two residents reviewed for abuse and neglect. An incident occurred in which one resident was found holding another resident down on the floor after staff responded to calls for help. Both residents involved had severe cognitive impairments, and neither could provide a clear account of the incident. Staff did not witness the event, and no injuries were noted at the time. The incident was documented in nursing notes and incident/accident investigation worksheets, but the investigation summary indicated a lack of clarity about what caused the incident and no witnesses to the event. Despite the facility's policy requiring an immediate investigation upon any allegation or suspicion of abuse, the abuse coordinator did not conduct a thorough investigation following the incident. The only documentation of the investigation was a brief typed note provided by the DON and interim administrator, which lacked detail and did not meet the facility's policy standards. The DON stated that she did not consider the incident to be abuse due to the absence of witnesses and injuries, while the interim administrator acknowledged that any unprovoked physical contact between residents should warrant an investigation by the abuse coordinator. The facility's policy, last reviewed in May 2025, specifies that the administrator is responsible for determining necessary actions to protect residents and that an immediate investigation is warranted when abuse is suspected or reported. However, the investigation into the incident involving the two residents was insufficient, as it did not follow the required procedures or provide a comprehensive review of the circumstances, leading to a deficiency finding by surveyors.