Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the investigation and reporting of abuse allegations for one resident. According to the facility's own policy, any complaint or suspicion of abuse is to be thoroughly investigated, the resident protected, the alleged perpetrator suspended, and the incident reported to the Department of Public Health and local law enforcement within two hours. However, when a resident with moderate cognitive impairment reported that a nurse threw a shopping bag at them and yelled, the incident was only addressed as a grievance. The Director of Social Services met with both parties, and the nurse apologized, but no formal investigation or documentation of interviews was completed, and the incident was not reported to the appropriate authorities at the time. The Administrator confirmed that the grievance was considered resolved without further investigation or reporting, as he did not view the incident as potential abuse but rather as a customer service issue. There was no evidence in the Health Care Facility Reporting System that the incident was reported as required by policy. The lack of immediate protection for the resident, failure to suspend the implicated staff member, and absence of a timely investigation and reporting process constituted a failure to follow established abuse prevention and response protocols.