Failure to Follow Abuse Reporting and Prevention Policies Involving Resident’s Personal Property and Restraint
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property for one resident. The resident was an older male with diagnoses including vitamin deficiency, pain, hypertensive heart disease, type 2 diabetes, and muscle weakness. His quarterly MDS showed a BIMS score of 12/15, indicating moderately impaired cognition, and his care plan identified potential risk for impaired cognitive function related to psychotropic drug use, history of stroke, and mild cognitive impairment, with interventions focused on clear communication, reorientation, and supervision as needed. According to interviews and record review, during a night shift a LVN took the resident’s personal cell phone without his consent and did not return it for the remainder of the night, planning instead to return it the following morning. The resident reported that two staff members were involved, with one staff member holding his hand while the other removed his phone, and that he was unable to call anyone until the next day. Further investigation confirmed that a CNA held the resident’s arms down and did not assist him out of bed, and that the resident’s wheelchair was removed and assistance with mobility was refused, which restricted his movement and was identified as a form of physical restraint. The incident was not reported to the Administrator or DON at the time it occurred, despite the facility’s abuse prevention and investigation policy requiring immediate reporting of all alleged violations to the Administrator and appropriate agencies within specified timeframes. The Administrator and DON both stated they were not notified during the night shift and only became aware when the resident reported the incident the following day. The LVN acknowledged taking the phone and not notifying the Administrator, stating she did not initially think of it, and the CNA stated the incident was not reported and believed the nurse in charge was responsible for reporting. This failure to follow the facility’s abuse, neglect, and exploitation policy regarding reporting, investigating, and responding to allegations of abuse constituted the deficiency.
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