Failure to Investigate and Document Alleged Abuse by Visitor
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for one resident. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and anxiety, was the subject of an incident in which a visitor was observed angrily pounding on her bed and yelling at her to wake up. The resident was also heard asking the visitor why they were always so mean to her. This incident was documented in the resident's progress notes. Despite the documentation of this event, the facility administrator confirmed that no investigation was conducted because she was unaware of the incident and had not reviewed the progress note prior to the surveyor's inquiry. The facility's policy requires prompt reporting and investigation of all suspected abuse, including verbal abuse by visitors, and mandates reporting to the appropriate authorities within specified time frames. However, in this case, the required investigation and reporting did not occur.