Failure to Investigate and Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse policy and procedures by not investigating or reporting a resident's allegation of abuse to the appropriate local, state, and federal agencies. During an incident involving a resident with intact cognitive status and a diagnosis of schizophrenia, three staff members met with the resident to discuss discharge planning. The resident reported that one staff member told her she was not wanted in the facility, swung her around in her wheelchair, and hurt her left arm, prompting her to call 911. Staff interviews confirmed a meeting took place and that the resident became agitated and screamed, but staff denied the alleged abuse. Despite the resident's clear report and the involvement of law enforcement, no internal investigation was initiated, and the incident was not reported as required by facility policy. The administrator acknowledged hearing the resident scream and being aware of the police response but chose not to investigate further, citing the resident's dislike of him and his belief that no abuse had occurred. The facility's policy required assignment of an investigation for any reported or suspected incident of abuse, mistreatment, neglect, or injury of unknown source, but this process was not followed. The failure to investigate and report the resident's allegation constituted a breach of the facility's abuse investigation and reporting procedures.