Failure to Implement Abuse Prevention Policies and Complete Required Assessments
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, specifically in the case of a resident with multiple medical conditions including dementia, Parkinson's disease, atrial fibrillation (on anticoagulant therapy), and behavioral issues such as agitation and physical aggression. The resident was found with unexplained bruises on multiple occasions, and the family member repeatedly raised concerns about possible abuse. Despite these incidents, the facility did not consistently complete or document required abuse/neglect assessments after each allegation or incident of bruising, nor did they update the abuse care plan following new allegations. Observations and interviews revealed that the resident was prone to bruising due to her medication and behavioral tendencies, such as swinging her arms and resisting care, which could result in accidental injury. Staff acknowledged the use of protective devices like Geri sleeves and padded chairs, but there was inconsistency in their application and documentation. For example, the resident sometimes refused protective devices, but refusals were not documented, and staff could not confirm consistent use of interventions intended to prevent injury. Record review showed that the facility's abuse prevention policy required ongoing assessment, care planning, and monitoring of residents at risk for abuse or neglect. However, there was no evidence of completed abuse/neglect assessments for the resident in 2025, including after significant changes in condition or following allegations of abuse. The facility also lacked a specific policy on resident safety and prevention of injury, and failed to document refusals of assessments or update care plans as required by their own procedures.