Failure to Investigate and Report Alleged Abuse
Penalty
Summary
Facility staff failed to thoroughly investigate an allegation of abuse involving a resident who was found with a red mark on their forehead. A family member discovered the mark and reported it to staff, who informed them it was not reportable. The incident was not initially documented or reported as required. Multiple staff members, including a unit manager and an LPN, observed or were informed about the mark but did not provide written statements or initiate a formal investigation at that time. The DON assumed the mark was caused by a TV remote, although no one witnessed this, and there was no evidence to support this explanation. Interviews revealed that neither the unit manager nor the LPN were asked to provide written statements regarding the incident. The administrator later acknowledged that the family member had alleged someone hit the resident, confirming the event was reportable. However, the allegation was not reported to the appropriate authorities or investigated until after surveyor intervention. The lack of timely reporting and investigation constituted a failure to respond appropriately to an alleged violation.