Failure to Investigate Allegation of Exploitation
Penalty
Summary
The facility failed to ensure that an allegation of exploitation involving a resident was fully investigated. The incident began when a report from another state agency regarding possible exploitation of the resident was received by the State Agency. Upon review, it was found that the facility did not submit a self-report or a thorough investigation related to the allegation. When requested, the Executive Director confirmed that there were no incident or investigation records available for the case. Interviews with staff, including an LPN, CNA, Social Services staff, and the ADON, revealed that while staff understood the importance of investigating abuse and exploitation allegations, they were either unaware of the specific incident or confirmed that no investigation had been conducted. The Social Services Director noted awareness of the exploitation concern due to non-payment issues and mentioned that a friend of the resident was restricted from visiting, but no facility-led investigation was documented. The facility's policy, reviewed in November 2024, requires that all alleged violations be thoroughly investigated to prevent further abuse, neglect, exploitation, or mistreatment. Despite this, the facility did not follow its own procedures in this case, as evidenced by the lack of documentation and investigation into the reported exploitation. The failure to investigate was confirmed through staff interviews and the absence of required reports in the facility's records and the State Agency database.