Failure to Submit Abuse Investigation Findings to State Agency
Penalty
Summary
Facility staff failed to submit the findings of an abuse investigation to the state agency as required by both facility policy and regulatory requirements. An incident involving an allegation of sexual misconduct between a resident with severe cognitive impairment and a certified nurse's aide was initially reported to the state agency. The facility completed its internal investigation and documented that the allegation was not substantiated, but there was no evidence that the final investigation report was sent to the state agency. During interviews, the administrator indicated a belief that the former DON had submitted the findings, but upon review, no documentation could be produced to confirm that the final report was sent. The facility's own policy requires that a complete written report of the investigation be filed with the state agency within five working days of the incident. This deficiency was confirmed through staff interviews, document review, and clinical record review, with no further information provided by facility leadership prior to the end of the survey.