Failure to Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse, as well as injuries of unknown origin, were thoroughly investigated for three residents. In one instance, a resident with moderately impaired cognition was verbally abused by another resident, resulting in emotional distress. The facility did not initiate an investigation into this incident until three days after it occurred, and failed to investigate a subsequent similar incident involving the same residents. The Administrator confirmed that the required investigations were either delayed or not conducted at all. Another resident with severe cognitive impairment and multiple medical diagnoses experienced physical aggression and later sustained injuries of unknown origin. Although these incidents were documented in nursing notes and discussed in interdisciplinary team meetings, the facility did not initiate any formal investigations to determine the cause or identify responsible parties. There was no evidence of staff interviews, injury assessments of other residents, or follow-up actions consistent with a proper abuse investigation, as required by the facility's own policy.