Failure to Investigate and Protect After Alleged Abuse and Improper Medication Administration
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment, who was physically restrained and administered morphine against her wishes. The resident, who had diagnoses including malignant neoplasm of the breast, hypertension, dementia, depression, and anxiety, was identified as being at high risk for exploitation and unable to accurately report abuse. Staff statements indicated that the resident was yelling for help and refused medication, but a registered nurse instructed staff to hold the resident's hands down and administered the medication despite her resistance. The nurse also made dismissive remarks when the resident expressed distress about being restrained. Despite being informed of the incident and staff concerns, the DON did not interview the nurse involved or follow up with the resident or other staff present during the incident. The nurse continued to work the following day, and no immediate protective measures were implemented for the resident or others. The facility's abuse prevention policy required immediate protection and investigation, including suspension of the alleged perpetrator and assessment of the alleged victim, but these steps were not followed after the incident.