Failure to Notify Guardian of Abuse Investigation Results
Penalty
Summary
The facility failed to provide timely notification to a resident's guardian regarding the results of an investigation into an allegation of physical abuse. The resident, who had diagnoses including psychosis, malnutrition, severe dementia with agitation, cognitive communication deficit, drug-induced dyskinesia, mood disorder, bipolar disorder, and anxiety, resided on a secured nursing unit due to safety concerns and a history of elopement. The resident's care plan included interventions for her cognitive and behavioral needs. On the date in question, the resident alleged that another resident had assaulted her in her room. The guardian, present at the time, reported the allegation to facility staff and requested to be informed of the investigation's outcome. Despite the guardian's repeated requests for updates via email and in person, there was no documentation that the facility notified the guardian of the investigation results. The facility's records did not reflect any communication with the guardian regarding the outcome, nor did they document the alleged altercation or the abuse allegation in the resident's clinical record. The investigation concluded that no assault had occurred, but this information was not relayed to the guardian until it was brought to the attention of the surveyors during the interview process.