Failure to Investigate Alleged Verbal Abuse Documented in Resident Council
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents out of five reviewed for abuse in a sample of ten. According to the facility's Abuse Prevention and Reporting policy, all staff are required to report any incident, action, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation of resident property immediately to the administrator or a designated individual. The policy defines abuse broadly, including verbal and mental abuse, and outlines specific examples such as mocking, insulting, threatening, or isolating residents. Despite these clear requirements, the facility did not initiate investigations into two separate allegations of verbal abuse that were documented in the Resident Council meeting minutes. One incident involved a dietary staff member telling a resident, "no you are too fat" when the resident requested a snack. Another incident involved the Social Services Director asking a resident if he would like to be homeless and stating that he would be put in a shelter. The Activity Director, who was responsible for conducting Resident Council meetings and recording the minutes, stated she had never been educated on how to handle concerns or complaints raised during these meetings. Both the Administrator and the Regional Director confirmed that no abuse investigations were conducted for either of the verbal abuse allegations documented in the Resident Council meeting minutes.