Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into abuse allegations involving three residents. In the first case, a cognitively intact resident reported that another resident with severe cognitive impairment touched her breast on two occasions, with the second incident perceived as intentional. The incident was reported to staff, but the facility did not complete a comprehensive investigation or contact law enforcement, as required by policy. In the second case, a resident with paraplegia made sexually inappropriate threats toward a severely cognitively impaired resident in the presence of staff. Although staff intervened verbally, the facility did not conduct a thorough investigation or notify the police, citing the residents' lack of desire to press charges as the reason for inaction. In the third case, a cognitively intact resident reported to hospital staff that he felt verbally abused and intimidated by facility staff. The facility received this information soon after the resident's hospital admission but did not initiate a timely investigation, with the administrator stating the investigation occurred over a week after learning of the allegation. These failures to promptly and thoroughly investigate abuse allegations, as well as to notify appropriate authorities, were contrary to the facility's own policies and procedures.