Failure to Investigate and Report Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an incident of potential resident abuse involving a resident and her family members. Nursing documentation indicated that a family member was observed force-feeding the resident, aggressively forcing her head forward, shaking her shoulder, and yelling at her, despite the resident expressing discomfort and refusing food. Staff documented concerns about mistreatment and reported the situation to a supervisor, but no incident report was completed, and no witness statements were obtained from those present during the incident. The facility did not remove the family members from contact with the resident to ensure her safety during the investigation, as required by policy. Additionally, the facility did not notify the appropriate regulatory agencies, such as the Department of Health or Area Agency on Aging, about the alleged abuse. The facility's abuse prevention policy referenced state-specific guidelines for Illinois and Missouri but did not include Pennsylvania's regulatory requirements. Interviews with staff and family confirmed the incident and the lack of a formal investigation or reporting. The Director of Nursing acknowledged that no incident report was filed and that the required steps to protect the resident and investigate the allegation were not taken.