Failure to Investigate Resident Abuse and Rough Care Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse were thoroughly investigated for three residents. One resident with dementia and a need for assistance with personal care reported that another resident entered her room, took her nice clothes, and that some clothing sent to the laundry never came back. She stated she had informed staff that the other resident came into her room and that she might slap the other resident because staff did not watch her. She later reported that the same resident entered her room around 4:00 a.m. while she was asleep and took a pillow from the other bed, after which she called the nurse and staff removed the other resident from the room. The resident alleged perpetrator had dementia with behavioral disturbance and psychosis, with a care plan problem for problematic behavior including verbal or physical aggression, wandering into other residents’ rooms, self-propelling around the facility, and agitation when she knew she was being monitored. Despite these behaviors and the allegations made by the first resident, review of the facility’s incident logs for December, January, February, and through mid-March showed no documentation of any incidents involving either of these two residents. The Administrator was informed of the allegation that the second resident entered the first resident’s room and that some property was missing, but the allegation was not entered into the incident log or reported to the State Agency when it was reported to the Administrator. A third resident, with dementia, abnormalities of gait and mobility, and a need for assistance with personal care, reported during a documented resident interview that care was “a little rough from the men,” specifying that male staff were a little rough getting him out of bed. The interview was completed by the Social Services Coordinator/Assistant, who stated she had been trained on abuse and neglect and that she sent the completed interview forms to the Social Services Director. However, she did not report the allegation to nursing, and no investigation of the allegation was completed. Review of the February incident log showed no documentation of this resident’s allegation, and facility leadership confirmed that the resident’s name did not appear on the log and that no investigation had been completed, despite expectations that reported allegations would be investigated timely.
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