Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to investigate an allegation of abuse in accordance with its own policy and procedure for one resident. The resident, who had a documented history of physical abuse, major depressive disorder, and anxiety disorder, was admitted following an incident of confirmed physical abuse by a family member. Upon admission, the care plan and interdisciplinary team notes clearly indicated that the resident did not want any contact with the alleged abuser, and staff were made aware of these wishes. Despite this, the family member was able to enter the facility on two separate occasions, with the second incident involving the family member forcing entry into the resident's room, shouting at the resident, and causing visible emotional distress. During the second incident, staff attempted to prevent the family member from entering the resident's room, but he pushed past them and tried to pull open the privacy curtain while the resident was receiving personal care. The resident was observed to be visibly upset, tearful, and shaking her head in refusal, and required administration of anti-anxiety medication following the event. Staff interviews confirmed that the resident was traumatized by the encounter and that the family member's behavior was verbally and emotionally abusive. The incident was not thoroughly investigated or reported to the state agency as required by the facility's abuse prevention policy. The administrator, who served as the abuse coordinator, acknowledged that she was not fully informed of the details of the incident and did not conduct an interview with the resident regarding the situation. The facility's policy required prompt and thorough investigation of abuse allegations, including interviews with the resident and witnesses, documentation of findings, and protection of the resident from further abuse, such as offering a room change. However, there was no evidence that these steps were taken following either incident involving the family member.