Failure to Prevent and Report Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to develop and implement written policies and procedures that effectively prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. This deficiency was identified through the case of a female resident with severe cognitive impairment, dementia, and multiple comorbidities, who was dependent on staff for all activities of daily living. The resident's care plan noted a risk for physical behaviors related to dementia, with interventions to analyze triggers and document de-escalation strategies. Despite these documented needs, the facility did not have effective interventions or services in place to address her care, resulting in the resident sustaining a comminuted and mildly displaced fracture of the right thumb, with extension to the first digit joint. The incident occurred when two CNAs were providing care to the resident. According to interviews and video evidence, the CNAs pulled the privacy curtain around the resident's bed, blocking the view of the camera. Audio from the video captured the resident shouting "stop" and screaming in pain. After the care was completed, the resident was observed with a bruised and swollen right thumb, which was later confirmed by X-ray to be fractured. The resident and her roommate both reported that the injury occurred during morning care, with the roommate hearing the resident cry out in pain. The CNAs involved did not report the injury at the time, and there was no documentation or explanation provided for how the injury occurred. Further review revealed that the facility's abuse, neglect, and exploitation policy emphasized residents' rights to be free from abuse and to have personal privacy respected. However, the policy was not effectively implemented, as evidenced by the lack of timely reporting, inadequate documentation, and failure to protect the resident from harm during care. The incident was only discovered after the resident was unable to use her hand, prompting further assessment and eventual transfer to the hospital. The facility's failure to implement its own policies and procedures directly contributed to the resident's injury and the subsequent identification of an Immediate Jeopardy situation.