Failure to Timely Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to timely investigate and report the results of abuse allegations within five days as required by policy. A resident with left and right hemiplegia and dysarthria, but no memory impairment, reported to the charge nurse that another resident allegedly kissed her forehead while she was asleep and that a staff member, specifically an X-ray technician, touched her inappropriately on her shoulder, forehead, and breast, and called her beautiful. Documentation showed that the resident reported these incidents on 8/3/25, but the 5-day investigation letters for both the staff-to-resident and resident-to-resident allegations were not completed until 8/11/25, eight days after the initial report. Interviews confirmed that the administrator, who was the primary investigator, acknowledged the investigation was not conducted in a timely manner. The resident expressed feeling uncomfortable, ignored, and disappointed by the lack of urgency from the facility. Staff interviews indicated awareness of the protocol to report and document abuse allegations promptly, and a CNA observed the resident crying after the incident. The facility's policy required a written report of the investigation findings to be provided to the appropriate agencies within five working days of the incident, which was not met in this case.