Failure to Investigate and Document Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an allegation of staff-to-resident physical/sexual abuse as required by its own abuse policy. The facility’s policy dated 10/16/23 states that residents have the right to be free from abuse, neglect, and exploitation, and that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property will be investigated and reported within required timeframes. Despite this, the medical record for one resident contained no documentation of any investigation, incident report, or interventions related to an allegation of abuse by staff. During observation and interview, the resident reported that while being assisted with toileting by a male CNA, she repeatedly tried to direct him to pull her underwear up in the front, but he continued pulling from the back until he finally adjusted them correctly. She stated that when she bent forward to position herself to walk back to bed, the CNA then took his hand and smacked her on the butt, which made her angry and led her to tell him to leave her room. The DON acknowledged being informed on the morning after the incident that the resident needed to speak with her about what she was reporting, and the Administrator in Training, who is the abuse coordinator, confirmed he was notified of an allegation involving this resident and the CNA. However, the abuse coordinator stated he did not report the allegation, did not conduct or document interviews related to this allegation, did not interview other residents about the CNA, and had no investigation or related documentation to provide.
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