Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents. In one incident, two cognitively intact residents with significant behavioral histories were involved in a physical altercation in the lobby after a dispute over elevator access. The facility's self-reported incident (SRI) did not identify witnesses or a perpetrator, and the allegation of abuse was unsubstantiated. Documentation showed that one resident had a history of physical aggression and behavioral issues, yet was not placed on a secured unit due to his refusal, despite ongoing threats and aggressive behavior toward others. Another resident with moderate cognitive impairment and behavioral disturbances was involved in several incidents, including making sexually explicit comments to staff, attempting to hit another resident, and becoming physically aggressive during a dispute. On one occasion, after a resident believed another had spit on him, he attempted to punch the other resident. The facility did not file an SRI for this incident, and documentation was limited to separating the residents and providing emotional support, without a thorough investigation as required by policy. A third resident, who was severely cognitively impaired and had a history of delusions and disruptive behaviors, reported to the psychiatric nurse practitioner that a peer had touched her breast after she lifted her shirt. The administrator was unaware of this allegation, and no investigation was initiated because staff did not report the incident. The facility's policy requires all allegations of abuse to be investigated and residents to be protected during investigations, but this was not followed in these cases.