Failure to Implement Abuse Investigation Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse involving one resident. According to the facility's own policy, all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation, misappropriation of resident property, and injuries of unknown source are to be investigated. However, documentation and staff interviews revealed that an allegation of abuse was not reported to administration and was not investigated in accordance with these policies. The resident involved had diagnoses including cachexia, dysphagia, and hypothyroidism, and was assessed as cognitively intact. Progress notes indicated that the resident experienced acute lower back pain following care provided by a nurse aide, with the resident and family both raising concerns about the care received. Despite these complaints and the facility's policy requirements, the incident was not promptly reported or investigated by administration as an abuse allegation. The deficiency was identified through review of facility documents, clinical records, and staff interviews, which confirmed that the required procedures for investigating abuse allegations were not followed for this resident. The Director of Nursing acknowledged that the facility failed to implement its written policies and procedures in this case.