Failure to Investigate and Report Alleged Abuse Incident
Penalty
Summary
The facility failed to initiate and complete a thorough investigation into an alleged incident of abuse involving a resident with moderately impaired cognition and diagnoses including unspecified dementia and mood disturbance. On the date of the incident, three staff members witnessed a domestic aide approach the resident from behind, pick them up in a bear hug, drop them on the floor, and then carry them to their room. These staff members reported the incident to two different registered nurses and the Director of Nursing. However, there was no evidence that the nursing staff reported the allegation to the facility administrator or that an investigation was conducted, as required by the facility's abuse policy. Interviews revealed that the Director of Nursing did not initiate an investigation, stating that the incident was not described to them in terms that raised suspicion of abuse. The Director of Nursing relied on the information provided by the registered nurses and did not pursue further inquiry. The facility's abuse policy mandates immediate documentation, reporting, and investigation of any suspected mistreatment or abuse, including notification of the administrator and completion of incident reports. These procedures were not followed in this case, resulting in a failure to respond appropriately to the alleged violation.