Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse prevention program policy when staff members did not immediately report suspicions or observations of abuse involving three cognitively impaired residents. Specifically, an LPN observed a resident inappropriately touch another resident but delayed reporting the incident for several days, waiting until after the weekend to notify the Director of Nursing (DON) via text. Additionally, a CNA witnessed another resident fondling a peer and engaging in further inappropriate behavior but only reported the incident to the LPNs on duty, not to the DON or Administrator until the following day. The DON, upon receiving the report, also delayed informing the Administrator until a scheduled managers' meeting the next morning. The residents involved had significant cognitive impairments and behavioral health diagnoses, including dementia, encephalopathy, and psychiatric disorders. One resident had a care plan addressing socially inappropriate behaviors, but another resident with a history of behavioral disturbances lacked documentation or a care plan regarding sexual behaviors. Staff reports about the incidents were inconsistent, making it difficult for psychiatric providers to determine the accuracy and extent of inappropriate sexual behaviors. The facility's abuse prevention policy required immediate reporting of any incident, allegation, or suspicion of abuse to the Administrator or person in charge, regardless of the time or day. However, staff failed to follow this policy, resulting in delayed initiation of investigations and reporting to appropriate agencies. The lack of timely reporting and inconsistent documentation contributed to the deficiency cited during the survey.