Failure to Report and Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to report, investigate, and submit a completed investigation report to the State Agency within the required timeframe regarding allegations of potential abuse involving two residents. Facility policy mandates immediate reporting of any allegations or suspicions of abuse, neglect, misappropriation, or exploitation to the Administrator, DON, or designee, and requires notification to law enforcement and the State Agency within specified timeframes. Despite this, incidents involving a resident with moderate cognitive impairment and a history of inappropriate sexual comments and touching were documented in progress notes, including one event where the resident pulled another resident's shirt and another where the resident held hands with a different resident and attempted to follow them. These incidents were not reported to the State Agency as required. The residents involved had significant cognitive impairments and required substantial assistance with daily activities. One resident had diagnoses including Alzheimer's Disease, dementia, anxiety, and depression, and a history of inappropriate behaviors. The other resident had severe cognitive impairment, exhibited physical and verbal behaviors, and was dependent on staff for care. Documentation revealed that the incidents were not reflected in the facility's reported incidents log for the past 12 months, and interviews with the Administrator and DON confirmed that the required reporting did not occur.