Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident abuse and did not ensure the protection of residents from further potential abuse during the course of the investigation. In one instance, a resident with dementia and severe cognitive impairment was reportedly exposed to another resident who approached their room with their pants down. The incident was witnessed by the resident's representative, who intervened and reported the event to nursing staff and later to facility administration. Despite these reports, the facility did not document the allegation as possible resident-to-resident abuse, did not report the incident to the State Survey Agency (SSA), and did not conduct a thorough investigation or implement protective measures during the investigation period. In another case, a resident with Alzheimer's disease and severe cognitive impairment was found by staff being struck by their roommate, who also had severe cognitive impairment and a history of behavioral problems. The staff member who witnessed the incident reported it to the charge nurse and DON, and the incident was discussed in an interdisciplinary team meeting. However, the facility did not report the altercation to the SSA, did not conduct a thorough investigation, and did not ensure protective measures were in place for the residents involved during the investigation. Interviews with facility staff, including the DON, Administrator, and other nursing staff, confirmed that decisions regarding reporting to the SSA were deferred to the Administrator, and that resident-to-resident altercations were not consistently reported or investigated as required by facility policy. The facility's policy stated that all allegations of abuse would be investigated and that residents would be protected from further potential abuse during investigations, but this was not followed in the cases reviewed.