Failure to Investigate Abuse Allegation Reported by Hospital
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living. The resident, who had a history of being combative and refusing care, was hospitalized following an unwitnessed fall. During the hospital stay, the resident reported to hospital staff that they had been assaulted or mistreated by facility staff. This information was documented in the hospital records and communicated to the facility upon the resident's return. Despite the documentation of the abuse allegation in the hospital records and the facility's own policy requiring thorough investigation of all abuse allegations, the facility did not initiate an investigation. Interviews with the social worker, DON, and administrator confirmed that they became aware of the allegation through hospital discharge documents but did not proceed with a formal investigation, as they believed a lack of verbal communication from the resident or family did not necessitate further action. The facility instead updated the resident's care plan to require two staff members for all care, but did not contact the resident's power of attorney or follow the policy for investigating abuse allegations.