Failure to Immediately Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple medical conditions, including Multiple Sclerosis, Hemiplegia, and Adjustment Disorder. The resident, who had intact cognition and required assistance with activities of daily living, reported to the Director of Recreation and a nursing supervisor that two Certified Nursing Assistants had threatened to slap them if they pressed the call bell again. The Director of Recreation documented the allegation but did not immediately report it to the appropriate supervisory staff, citing a lack of specific details such as the staff member's name or the date of the incident. Instead, the written statement was placed in the mailboxes of the Social Worker and, purportedly, the Director of Nursing, but was not directly communicated to them. As a result, the Social Worker and Director of Nursing were not made aware of the allegation until several days later, delaying the initiation of an internal investigation. The facility's policy required immediate reporting and prompt initiation of investigations into abuse allegations, but this process was not followed. There was no documented evidence that an investigation was started until days after the initial report, and no immediate measures were put in place to protect the resident from further potential abuse.