Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated for three residents. In one incident, a resident with moderate cognitive impairment and multiple diagnoses, including schizoaffective disorder and major depressive disorder, was found in another resident's room with his penis exposed and was observed touching the other resident's breasts over her clothing. Both residents involved were moderately cognitively impaired. The incident was documented in the medical record, and staff interviews confirmed the details. However, the police were not notified of the alleged abuse, and there was no evidence that a thorough investigation was conducted as required by facility policy. In a separate incident, the same resident was observed exposing himself and touching his penis in front of another resident who was rarely understood and had vascular dementia and other significant health conditions. Staff interviews confirmed that this behavior had occurred, but the DON verified that an investigation was not conducted for this allegation of abuse. Facility policy requires that an investigation be conducted once the Administrator and Department of Health are notified, but this was not followed in these cases.