Failure to Initiate Timely Investigation of Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for investigating an allegation of suspected physical abuse involving a resident who reported being sexually assaulted by another resident. The incident was reported to the facility Administrator on April 2, 2025, but there was no documented evidence that an investigation was initiated within the specified timeframes. The facility's policy requires that all allegations of abuse, neglect, exploitation, or theft/misappropriation of resident property be thoroughly investigated and documented, with findings reported to the appropriate agencies. However, interviews with facility leadership, including the Program Director, Director of Nurses, and Administrator, confirmed that the investigation was not started as required by policy. The resident involved had a history of schizoaffective disorder and major depression and was assessed as cognitively intact with a BIMS score of 14. The allegation was reported to the Ombudsman, who then informed facility staff, but the clinical record review from April 10 to April 16, 2025, showed no evidence of an investigation or interventions to address potential harm or prevent recurrence. Facility leadership acknowledged during interviews that the investigation should have been initiated immediately according to policy, but this did not occur.