Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple allegations of abuse involving six residents out of a sample of twenty-two. According to the facility's own policy, all alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect are to be thoroughly investigated, including immediate investigation and interviews with the resident or other witnesses. However, in several cases, such as when a resident called the police alleging theft and inappropriate touching by other residents, and when another resident reported being hit in the chest by a male friend, the facility did not conduct additional resident interviews as required. The Administrator confirmed that these interviews were not performed during the investigations. Further review revealed additional failures to investigate allegations. In one instance, a resident alleged that another resident put a hand around her neck while removing a smoking apron, and although staff intervened and separated the residents, there was no evidence of a comprehensive investigation. In another case, a hospital social worker reported concerns about bruises on a resident's body after a fall, but there was no documentation that this allegation was investigated. The Administrator acknowledged awareness of the report but confirmed that no investigation was conducted. These actions and inactions demonstrate a pattern of incomplete abuse investigations, contrary to facility policy.