Failure to Investigate and Report Allegation of Visitor Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident when staff observed a visitor flicking the resident on the nose in an aggressive manner while assisting with feeding. The resident had multiple medical conditions, including a femur fracture, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, and hypertension. Care plans and MDS assessments documented moderate to severe cognitive impairment, which could affect the resident’s decision-making and ability to assess personal safety. On the date of the incident, a CNA observed the resident’s friend flicking the resident’s nose and intervened by instructing the visitor not to continue the behavior. The visitor then became confrontational and yelled at the CNA. The CNA reported the incident to an RN, who documented the event in the electronic health record and notified the resident’s daughter, who requested that the matter be reported to the resident’s case worker. However, there was no documentation in the electronic health record or the facility’s grievance log that an allegation of abuse was reported or that a formal abuse investigation was initiated. Interviews with staff confirmed that the CNA reported the incident to the RN, and the RN reported it to the DON. The DON stated that he went to the facility, spoke with the resident, and, after discussing the situation with the Abuse Coordinator/Administrator, decided the incident did not meet criteria for abuse or neglect and did not report it to the state agency. The Abuse Coordinator confirmed awareness of the allegation and the decision not to report. This response did not follow the facility’s abuse prevention policy, which required that all allegations of abuse and neglect be thoroughly investigated, including interviews with the reporter, the resident, witnesses, and the alleged perpetrator, as well as review of the medical record and relevant circumstances.
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