Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse and mistreatment involving two residents. In the first incident, a resident with a history of psychiatric diagnoses and a BIMS score indicating intact cognition reported being fondled by a male resident. The LVN documented the resident's distress and her statement about being touched, and the DON was notified. However, the DON did not believe the allegation was reportable, citing the resident's cognitive status and the lack of direct disclosure during her own interaction with the resident. The administrator was aware of the allegation but did not interview the resident or initiate a formal investigation, referencing the resident's history of making unsubstantiated claims and the absence of witnesses. In the second incident, another resident with severe cognitive impairment and behavioral disturbances reported being hit by a female resident. The LVN documented the statement and observed the resident's agitation, but the DON was not made aware of the allegation and only learned of it during the survey. The administrator acknowledged seeing the nursing note but did not receive a formal report or initiate an investigation, as the resident could not recall the event and there were no witnesses. The LVN noted that the resident was moved to another unit following the incident, but no further documentation or investigation was completed. Interviews with facility staff revealed inconsistent responses to the allegations, with reliance on residents' cognitive status and the presence of witnesses as determining factors for reporting and investigating abuse. The facility's policy requires all allegations of abuse, neglect, or mistreatment to be promptly reported and thoroughly investigated, regardless of the circumstances. The failure to follow these protocols resulted in a lack of comprehensive investigation and documentation for both incidents, as required by facility policy and state regulations.