Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or theft involving nine out of ten residents were properly identified, reported, and investigated as required. Multiple residents, most of whom were cognitively intact or only moderately impaired, submitted concern forms detailing incidents such as being left without oxygen, being left in soiled briefs for extended periods, being spoken to in a rude or mean manner by staff, and having requests for care ignored or delayed. In one case, a resident alleged being sex trafficked, and in another, a resident reported that a CNA hid her call light and shut her door, leaving her to call out for help. Despite these serious allegations, the facility consistently categorized the complaints as customer service issues rather than potential abuse, and did not report them to the state agency as required. Administrator interviews revealed a pattern of minimizing or reclassifying resident complaints. The administrator often asked residents whether they considered incidents to be abuse or customer service concerns, sometimes after explaining the definition of abuse to them. In several cases, the administrator documented that residents did not feel abused after these discussions, but there was no evidence that the allegations were reported to the state agency for further investigation. In some instances, the administrator or other staff provided education to the staff member involved, but did not document any investigation or reporting of the abuse allegations. The facility's failure to recognize and report these allegations as abuse was further highlighted by interviews with other staff, including the DON, who acknowledged that some incidents described on concern forms could constitute abuse or involuntary seclusion. However, there was no documentation that these concerns were reported to the state agency. The lack of proper identification, reporting, and investigation of abuse allegations represents a significant deficiency in the facility's responsibility to protect residents from abuse and to comply with mandatory reporting requirements.