Failure to Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for abuse prevention, reporting, and investigation, resulting in unreported and uninvestigated incidents of physical and sexual abuse involving three residents. On one occasion, a staff member witnessed a resident physically assault another resident by punching them in the chest while in the elevator. Despite multiple staff being aware of the incident, there was no documented evidence that the event was reported to the State Survey Agency, Ombudsman, or law enforcement within the required timeframe, nor was there any documentation of an investigation into the incident. In a separate incident, several staff members observed a resident inappropriately touch another resident's inner thigh and upper back while waiting in the hallway. The staff who witnessed the event reported it internally, but the abuse was not reported to the appropriate authorities, and no investigation was documented. The resident who experienced the inappropriate touching expressed feeling scared and unsafe in the facility following the incident. Interviews with staff revealed a lack of knowledge and follow-through regarding mandated reporting requirements and the completion of necessary forms, such as the SOC 341. The residents involved had significant medical and psychological histories, including cognitive impairment, depression, schizophrenia, and histories of trauma. The failure to report and investigate these incidents, as well as to protect residents from further abuse, was confirmed through interviews, record reviews, and observations. The administrator admitted to not reporting or investigating the incidents, and staff interviews highlighted gaps in training and understanding of abuse reporting protocols.