Failure to Implement Abuse Prevention Policy for Resident Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy in the areas of identification, investigation, protection, and reporting for one resident. The facility’s policy, revised 09/13/2022, required staff training on identifying, recognizing, and reporting abuse/neglect, mandated investigation of all allegations, and required immediate reporting of alleged violations to the administrator, state agency, and other required agencies, as well as protection of residents during and after investigations. Resident 5, who had diagnoses including kidney and urinary disorders, hypertension, and bipolar II disorder and required set up/clean up assistance for ADLs, had intact cognition per a comprehensive assessment. On the date of the incident, the resident told one RN (Staff F) they no longer wanted another RN (Staff G) to care for them, citing that Staff G had not assisted with their catheter when requested, resulting in the resident urinating on themselves. Staff G, aware of the request, went to the resident’s room and questioned the resident about why they wanted a different nurse. According to Staff F’s interview, Staff G argued with the resident, demanded a reason for the requested change, refused to leave the room despite multiple requests, and remained even as the resident yelled for Staff G to get out. Staff F reported the incident to the DON (Staff B) the same day and wrote a witness statement regarding an allegation of verbal abuse, but did not report the incident to the State Agency. Staff B acknowledged that an allegation of abuse had been reported on that date, that witness statements were requested, and that the process should have included suspending Staff G to protect the resident; however, Staff G continued to provide care to the resident. The Administrator (Staff A) stated they were not informed of the staff-to-resident incident until six days later, and the incident was not entered into the facility’s incident reporting log covering the relevant period. The incident was not reported to the State Agency until several days after it occurred, contrary to the facility’s policy requiring immediate reporting of alleged violations.
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