Failure to Timely Report and Investigate Alleged Resident Mistreatment
Penalty
Summary
Staff failed to report and investigate an allegation of mistreatment involving a resident with diagnoses of cerebral infarction, dementia, and anxiety disorder. The resident, who was alert and oriented with a BIMS score of 14/15 and required moderate assistance for showers, reported to a staff member that they were inappropriately touched by another staff member during a shower. The staff member relayed the allegation to the ADON, but the ADON did not report or investigate the allegation, citing the reporting staff's disbelief in the event and a request not to discuss the matter further with the resident. The facility did not submit a reportable event to the State Agency as required, and the DON was not made aware of the allegation until later. Facility policy and the DON both require that all abuse allegations be reported immediately, investigated promptly, and reported to the State Agency within two hours of discovery. The failure to report and investigate the allegation in a timely manner, as well as the lack of notification to the State Agency, constituted a deficiency in the facility's handling of suspected abuse.