Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures prohibiting abuse, neglect, and mistreatment for two residents. In the first instance, a housekeeper reported to a registered nurse that a certified nursing assistant (CNA) was yelling, swearing, and handling a resident roughly during care. The registered nurse reported the incident to the nursing home administrator, but the CNA was not removed from resident care during the investigation. The facility's investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, and no additional interviews with other staff or residents were conducted. The incident was not reported to the State Agency as required by facility policy. In the second case, a family member raised concerns about staff approach and communication during a transfer of another resident who had recently transitioned to using an EZ stand. The family member reported that staff were abrupt, used a stern voice, and made inappropriate comments, causing the resident to become anxious and confused. The staff told the resident she could remain in the chair and go to the bathroom there, then left the room without assisting further. The family member reported the incident to the social worker, who documented it as a grievance. The social worker and administrator both acknowledged the incident could be considered abuse, but the incident was not reported to the State Agency, and a full investigation was not completed. Both incidents demonstrate that the facility did not follow its own abuse policy, which requires immediate safeguarding of residents, thorough investigation of all allegations, and timely reporting to the State Agency. In both cases, the facility failed to remove the alleged perpetrator from resident care during the investigation, did not conduct comprehensive interviews, and did not report the allegations as required by policy and regulation.