Failure to Investigate and Notify Law Enforcement of Physical Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and notify law enforcement regarding an allegation of physical abuse with injuries for one resident. The resident, who had diagnoses including acute respiratory failure, malnutrition, depression, anxiety, and seizure disorder, was able to communicate needs and reported pain and bruising after alleging that a staff member had hit them. Observations confirmed visible bruising on the resident's right knee and thigh, and staff interviews corroborated that the resident reported being hit and was observed with new bruises. Despite these reports and visible injuries, the facility's investigations attributed the injuries to the resident's own actions without obtaining witness statements or evidence to support this conclusion. The incident logs showed that both occurrences of injury were reported to the state hotline, but the facility's internal investigations ruled out abuse and neglect, citing the resident's cognition and diagnoses as the root cause. The investigations lacked documentation of staff witnessing the resident's alleged self-harm. Additionally, law enforcement was not notified, contrary to facility policy, which was acknowledged by the nurse manager upon review. The DON stated that law enforcement notification was only required when abuse was confirmed, and no environmental interventions were implemented despite claims of self-injury.