Failure to Notify Ombudsman of Abuse Allegations
Penalty
Summary
The facility failed to operationalize its abuse prevention policy by not notifying the Ombudsman of multiple abuse allegations, despite documentation indicating that such notifications had occurred. Specifically, investigation reports for several incidents of resident-to-resident physical abuse and an incident involving a nursing staff member causing a bruise to a resident's arm all stated that the Ombudsman was notified, as required by the facility's policy. These reports were documented by the Administrator/Abuse Prevention Coordinator. However, during an interview, the Ombudsman confirmed that he had not been notified of any of the abuse allegations listed in the reports. The Ombudsman reviewed his records, including notes, emails, and phone calls, and found no evidence of notification from the facility. He also stated that he was present in the facility during the relevant period and was not informed in person about any of the incidents. The facility's abuse policy requires immediate reporting of all abuse allegations to the Administrator and timely notification to authorities, including the Ombudsman, but this procedure was not followed.