Failure to Investigate and Respond to Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and misappropriation involving a resident with severe cognitive impairment, as indicated by a BIMS score of 03. Progress notes documented that the resident reported having a romantic relationship with a CNA, alleged sexual assault by an unidentified LPN, and claimed a CNA was living at their home and receiving monthly payments. These allegations were communicated to the ADON and administrator, but there was no evidence of an immediate or comprehensive investigation. Additionally, another progress note documented an allegation of stolen credit cards, but this was not reported to administration or investigated. Interviews revealed that the DON and administrator were either unaware of or did not act upon the documented allegations. The DON stated they had not seen the relevant progress notes or conducted any investigation, and the administrator indicated they had delegated the responsibility but did not follow up. The alleged perpetrator, CNA, was not suspended and continued working scheduled shifts. Staff interviews confirmed that allegations were either not communicated to the appropriate personnel or not acted upon, resulting in a lack of protective measures for the resident and failure to follow facility policy requiring immediate investigation of abuse, neglect, or exploitation.