Failure to Report and Investigate Resident Incident Involving Staff
Penalty
Summary
Facility staff failed to implement the abuse prevention and investigation policy when an incident occurred involving a resident and a registered nurse. The incident involved the nurse physically blocking the resident from entering the building and attempting to take a bag containing cigarettes from him, resulting in a tussle at the doorway and the resident's arm becoming caught. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following cerebral infarction, reported the incident during an interview. Two staff members, an LPN and a CNA, witnessed the event but did not document or report it to facility leadership as required by policy. The facility's policy mandates immediate reporting of any incident involving suspicion or allegation of mistreatment, exploitation, neglect, or abuse to the Administrator. Despite this, neither the LPN nor the CNA notified the Director of Nursing, Assistant Director of Nursing, or Administrator about the incident. The Director of Nursing and Administrator both confirmed they were not informed and stated that an investigation would have been initiated had they been notified. The failure to report and investigate the incident constituted a breach of the facility's abuse prevention and investigation policy.