Failure to Operationalize Abuse Policy Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to operationalize its abuse policy and procedures for two residents with cognitive impairment. An incident occurred in which one resident, who had a history of working as a CNA and was now a resident with some confusion and dementia, was found by an LPN on her knees next to her roommate's bed with her pants down and her hand in the buttocks region of her roommate, who also had severe dementia and was non-communicative. The LPN observed the resident placing her middle finger near the roommate's rectum, with both residents and the bedding soiled with fecal matter. The LPN immediately intervened, separated the residents, and notified management and authorities. Despite the eyewitness account and documentation by the LPN, the facility's internal investigation concluded that no inappropriate contact had occurred, attributing the incident to a misunderstanding and the resident's confusion. The administrator and DON expressed doubt that abuse had occurred, citing the resident's prior CNA experience and confusion, and did not fully address the eyewitness statement or the police report, which described digital manipulation of the roommate's vagina and anus. The facility's documentation did not include a statement from the non-communicative resident or a thorough account of the LPN's observations in the final report. The facility's abuse policy outlines steps for investigation, including interviews with witnesses and review of relevant documentation. However, the investigation omitted key details from the eyewitness account and did not document the incident in the roommate's nursing notes. The facility requested past noncompliance for F600 abuse, despite the lack of findings in their internal investigation and the presence of conflicting evidence from staff and police reports.