Failure to Timely Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough and timely investigation into allegations of abuse made by a resident with severe cognitive impairment and a history of delusional disorders. The resident, who was diagnosed with dementia and delusional disorders and had a BIMS score of zero, reported that staff and other residents were trying to harm her. On the evening in question, the resident left the facility and was found at a grocery store across the street, visibly upset and fearful, stating that other residents were trying to kill her. Upon her return, she was assessed for injuries and placed on 15-minute checks, but no immediate or comprehensive investigation was initiated at that time. The facility's abuse policy required immediate reporting and investigation of any suspected abuse, including interviewing all relevant parties and implementing interventions to ensure resident safety. However, the investigation into the resident's allegations was delayed. The social services director indicated that the administrator wanted to consult with superiors before starting the investigation, resulting in a lack of prompt action. Additionally, the family member interviewed during the investigation was not involved in the incident, and key individuals such as the resident's son and the pharmacist who interacted with the resident during the event were not contacted by facility staff for information about the incident. Staff interviews confirmed that the required process for abuse allegations was not followed as outlined in facility policy. The delay in initiating the investigation and the failure to interview all relevant parties, including those directly involved or with firsthand knowledge of the resident's statements and behavior, contributed to the deficiency. The facility did not ensure that all alleged violations were responded to appropriately and in a timely manner, as required by their own procedures.