Failure to Investigate and Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate and report multiple allegations of abuse, neglect, and mistreatment involving several residents. Incidents included sexual contact between residents with severe cognitive impairment, elopements, injuries of unknown origin, and fractures. In several cases, residents with diagnoses such as dementia, psychotic disorders, and traumatic brain injuries were involved in situations where their ability to consent was questionable, yet no formal investigations were conducted. For example, one resident with a BIMS score indicating severe cognitive impairment was found in close proximity or engaging in physical contact with other residents on multiple occasions, but the facility did not document any investigation into these incidents. In another case, a resident was found with another resident in a compromising situation, and although staff separated them, no investigation was initiated, and the event was not reported to the State Survey Agency. The facility also failed to investigate and report multiple elopement incidents. Residents with significant cognitive impairment and a documented history of wandering or elopement risk were able to leave the facility premises on several occasions. In some instances, residents were found outside the facility or even on public streets, and staff had to intervene to bring them back. Despite these events, there was no evidence of a formal investigation or reporting to the State Survey Agency. Staff interviews confirmed that these incidents were not investigated or reported as required, and the administrator acknowledged that these events should have been handled differently. Additionally, the facility did not investigate injuries of unknown origin. For example, a resident with severe cognitive impairment was observed with a large bruise to her right eye, and although the incident was noted in the medical record, there was no documentation of an investigation to determine the cause. The DON stated that such injuries should be investigated and reported if the cause is unknown, but no investigation was provided. The administrator also confirmed that investigations were primarily informal and that some incidents were not reported due to a lack of clarity on reporting requirements.