Failure to Investigate Alleged Abuse Following Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving one resident. The resident, who was cognitively intact and had diagnoses including cachexia, dysphagia, and hypothyroidism, reported experiencing acute lower back pain after being turned by a nurse aide during incontinence care. The resident's family later inquired about the incident after receiving a phone call from the resident describing the care provided by the aide. Progress notes documented the resident's complaints of pain originating during care, and subsequent medical evaluations noted persistent lower back pain, with imaging revealing an indeterminate L4 compression fracture. Despite these reports and the facility's policy requiring investigation of all allegations and incidents of abuse, the allegation was not reported to administration, and a thorough investigation was not initiated until weeks after the incident, when the DON became aware through communication with the resident's family. The delay in reporting and investigating the allegation constituted a failure to respond appropriately to an alleged violation, as required by facility policy and regulatory standards.