Failure to Thoroughly Investigate and Timely Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse involving two residents and did not report one allegation within the required timeframe. For one resident with advanced dementia and a history of knee/leg pain, the resident reported leg pain and indicated a staff member had caused the injury. Although Adult Protective Services (APS) were notified, the facility's investigation concluded there were no concerns of staff involvement without conducting a thorough investigation to rule out abuse. Documentation did not show that all necessary investigative steps were taken. In another case, a resident reported pain and alleged that a staff member had penetrated them during assistance with a bath. The facility notified the Administrator and, two days later, APS. The investigation did not substantiate the allegation, citing the resident's behavioral history and a diagnosis of urinary tract infection, but failed to include interviews with the roommate, other residents, or staff to ensure a comprehensive review. The facility Administrator confirmed that thorough investigations were not completed for either incident and that timely reporting requirements were not met for the second allegation.