Failure to Timely Investigate and Protect Residents After Abuse Allegations
Penalty
Summary
The facility failed to immediately respond, investigate in a timely manner, and implement resident protections following allegations of verbal, mental, and physical abuse, as well as neglect of care, for two residents. In the first case, a resident with dementia and impaired mobility required staff assistance for repositioning. The resident and a family member reported that a nursing assistant used inappropriate language and physically handled the resident in a rough manner, including throwing the resident's legs against the wall. The incident was reported to the social worker, and both the administrator and DON were notified. However, the investigation lacked interviews with other staff or residents, and there was no documentation of protective measures taken during the investigation. Progress notes did not mention the incident, and the staff member involved was not immediately suspended. In the second case, a resident with moderate cognitive impairment and limited mobility required assistance with activities of daily living and was at risk for pressure injuries. The resident's family member reported overhearing a nursing assistant refuse to provide timely incontinence care, make threatening statements about using the call light, and remove the resident from her room while she was wet and in her nightgown, placing her in a public area without her phone. The investigation documentation lacked interviews with other staff or residents, and the staff member was only removed from caring for the resident but continued to work with other vulnerable residents. The incident was not reported to the State Agency as required, and the investigation was not thorough. Interviews with facility staff, including the social worker, LPN, RN, and administrator, revealed inconsistencies and gaps in the investigation process. Staff acknowledged that best practices, such as suspending the alleged perpetrator and interviewing all relevant parties, were not followed. Facility policy required prompt reporting, suspension of the alleged perpetrator, and comprehensive investigation, but these steps were not consistently implemented. The administrator and DON did not ensure timely communication with families or complete documentation, and there was a lack of clarity regarding which incidents were reportable and how investigations should be conducted.
Removal Plan
- Reviewed and revised policies and procedures related to abuse reporting, protections, and investigating allegations of abuse.
- Educated all staff and leadership on the above policies and procedures with competency. Training included conducting thorough investigations.
- Assessed all residents for abuse who had contact with implicated staff.
- Care plans for R2 and other affected residents were updated to include specific protections and interventions.
- Staff involved in the allegations were removed from the schedule to eliminate access to resident pending completion of the investigations.
- Thorough investigations were completed for the incidents and were reported to the State Agency.