Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to appropriately identify, investigate, and report multiple allegations of abuse involving nine out of ten residents. In each case, residents or their representatives submitted concern forms or made statements describing staff behavior that included verbal abuse, neglect, rough or rude care, and, in one instance, an allegation of sex trafficking. Despite these reports, the facility did not recognize these as abuse allegations, did not initiate investigations, and did not report the incidents to the state agency as required. The facility's responses were limited to providing staff education or discussing the incidents with the involved parties, without further protective measures or formal documentation of investigations. Several residents, including those with cognitive impairments and those who were cognitively intact, reported specific incidents such as being left without oxygen, being forced to sit in soiled briefs, being spoken to rudely or with an attitude by nursing staff, and having call lights hidden or being left unable to call for help. In some cases, residents' family members corroborated the allegations, describing repeated patterns of staff misconduct and lack of timely response to resident needs. The facility's administration consistently categorized these concerns as customer service issues rather than abuse, even when residents explicitly stated they felt abused or when the nature of the complaint met the regulatory definition of abuse or neglect. Interviews with facility leadership, including the Administrator, DON, and Unit Manager, revealed a lack of recognition of abuse allegations and a failure to follow required protocols for investigation and reporting. Staff involved in the alleged incidents were not removed from resident care duties during the review of the concerns, and there was no evidence of five-day investigation reports being submitted to the state agency. Documentation of interviews and follow-up actions was either absent or insufficient, and in some cases, staff could not recall the incidents or the education they purportedly received. The facility did not ensure the safety of residents or comply with regulatory requirements for abuse prevention and reporting.