Failure to Investigate Alleged Involuntary Seclusion and Protect Resident During Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of abuse and to ensure resident safety during the investigation for one resident with severe cognitive impairment. Resident #7 had cerebral palsy, severe intellectual disabilities, a history of healed traumatic fractures, was dependent on staff for most ADLs, and did not ambulate. The resident’s MDS and care plan documented that he preferred to spend time in the common area watching TV, listening to music, and people watching, and that he communicated basic needs through body language and limited verbalizations. On a February day shift, Staff A CNA was documented as providing multiple ADL cares to the resident. Staff E CNA later reported that on a Saturday, Resident #7 was making vocalizations and Staff A placed him in his room and closed the door so she would not have to hear him, keeping him there for 45 minutes to an hour despite his preference to be out of the room. Staff E stated she reported this to Staff F RN, and that the resident’s roommate was present at the time. Resident #8, the roommate, stated that at times Resident #7 wanted out of the room and staff shut the door, and confirmed that Resident #7 liked to be in the common area. Staff F RN acknowledged that Resident #7 did not like to be in his room and communicated his wishes by grunting and pointing, and, after further questioning, confirmed that Staff E had reported to her that Staff A placed the resident in his room and closed the door, with the roommate activating the call light. Staff F believed the incident occurred a couple of weeks before it was reported to her and stated she only mentioned it to the DON “in passing.” Staff A denied closing the door against the resident’s wishes and stated she could interpret some of his gestures, and did not think she had cared for him that weekend. The DON and Administrator both stated that such an allegation should be reported to them, that residents should be free from abuse, and that they would have separated the alleged perpetrator from residents and reported and investigated the allegation. The facility’s abuse policy defined abuse to include involuntary seclusion and required timely reporting and thorough investigation, but did not specify how to protect residents during an investigation. The facility lacked documentation that any investigation was carried out or that residents were separated from Staff A prior to February 25.
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