Failure to Immediately Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy regarding the immediate reporting and investigation of abuse allegations for two residents. In the first case, a cognitively intact resident was alleged to have been struck by a nurse aide. The incident was initially reported by a nurse aide to a nurse, but there was confusion among staff about who was responsible for escalating the report. As a result, the Administrator was not notified until several hours after the initial disclosure, and the required notifications to authorities were delayed until the Administrator became aware of the incident. In the second case, another cognitively intact resident reported to Adult Protective Services and law enforcement after discharge that a female staff member had inappropriately touched him. The police investigator attempted to contact the facility's Administrator but was unsuccessful and instead spoke with the Social Worker Director, who did not recognize the staff description and did not report the allegation internally. The Director of Nursing and Administrator were unaware of the allegation until it was reported by the state, and no internal investigation was initiated until that point. Both cases demonstrate that the facility did not follow its own policy requiring immediate reporting of abuse allegations to the Administrator or management, nor did it ensure timely initiation of investigations. Staff interviews revealed a lack of clarity and communication regarding the proper procedures for reporting abuse, resulting in delayed notifications and investigations.