Failure to Include Required Elements in Abuse Prevention Policy
Penalty
Summary
Surveyors determined that the facility failed to develop and implement an abuse policy that met CMS requirements. The Resident Abuse Policy/Procedure provided for review did not show evidence of coordination with the facility’s QAPI program, did not include required training content regarding recognizing signs of abuse and identifying different types of abuse, and did not contain language prohibiting and preventing retaliation against individuals who report abuse. During interview, the NHA stated that the facility conducts extensive abuse training throughout the year but was not aware that the written abuse policy lacked these specific CMS-required elements, including training on signs and types of abuse, anti-retaliation provisions, and QAPI involvement. These findings were discussed with the NHA, DON, and ADON during the exit conference. No residents or specific patient conditions were mentioned in the report.
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