Failure to Thoroughly Investigate and Document Alleged Abuse and Bullying
Penalty
Summary
The facility failed to thoroughly investigate all alleged violations of abuse for two residents, both of whom were identified as offenders and had a history of incarceration together. One resident, who was cognitively intact and had multiple diagnoses including schizophrenia and cerebral palsy, reported being sexually assaulted and bullied by another resident. The care plans for both residents did not address the ongoing bullying or dominance behaviors, and there was no behavior tracking provided for the resident who reported the abuse. Multiple staff and another resident observed or were aware of the bullying and dominance behaviors, but these concerns were not consistently documented or investigated. Interviews with staff and residents revealed that the alleged perpetrator had a history of threatening and intimidating both residents and staff, including a nurse practitioner who reported being threatened. Despite these reports, the facility did not have documentation of any abuse investigations related to the bullying or the alleged sexual assault prior to the current administrator's tenure. The administrator and DON were both new to their positions and were unaware of previous allegations or investigations. The facility's abuse prevention policy required that all incidents and allegations be investigated and documented, but this was not followed in these cases. When the sexual assault allegation was finally investigated, the process was inconsistent, with residents being asked different questions and key witnesses not being asked about what they had observed. The investigation relied heavily on video surveillance, which did not substantiate the allegation, and the final report concluded the abuse was unsubstantiated. However, the lack of consistent and thorough investigation, as well as the failure to report the allegation to the state agency as required, constituted a deficiency in the facility's response to alleged violations.