Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate two separate allegations of abuse involving three residents. In the first incident, a staff member reported witnessing one resident strike another on the shoulder with a shoe. The administrator confirmed awareness of this event and acknowledged it as a potential abuse incident but did not initiate an abuse investigation. In the second incident, a resident was observed grabbing another resident's hair and clothing while self-propelling in a wheelchair near the nurses' station. The administrator became aware of this situation the following day and confirmed that an immediate investigation into the allegation of abuse was not started. These failures occurred despite facility policy requiring thorough investigation of all alleged violations of abuse.