Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate allegations of abuse involving one resident who was observed to be angry, agitated, and verbally aggressive toward other residents and staff. Progress notes documented that the resident was yelling and cursing at others, and staff intervened to redirect and calm the resident. Despite these documented incidents of verbal altercations, there was no evidence that an abuse investigation was initiated for the events that occurred on two separate dates. The incidents were only reported to the Director of Nursing several days later, and the required investigation had not been conducted as of the time of the survey. Interviews with facility staff confirmed that the incidents were reported late and that the Director of Nursing was not made aware of the situation until days after the events occurred. The facility's own Abuse Prevention policy requires immediate initiation of an investigation upon any finding of abuse or neglect, but this was not followed. Documentation also indicated that the nurse entered progress notes as late entries, further delaying the reporting and investigation process.