Failure to Investigate and Protect Residents Following Alleged Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations and maintain evidence of investigations into multiple alleged incidents of abuse, neglect, and injuries of unknown origin. In several cases, the facility did not obtain or document staff and resident interviews, body audits, or other investigative steps as required by policy. For example, after an alleged altercation between two residents, there was no evidence of an investigation or documentation, and the incident was not reported to the state agency. In another case, a resident sustained rib fractures, but the facility's investigation lacked interviews with staff or residents and did not include body audits to rule out abuse or other causes. The facility also failed to protect residents from potential further abuse by not immediately removing alleged abusers from the premises. In one incident, an LPN accused of being rough and verbally abusive to a resident was allowed to continue working and interacting with the resident for several hours after the allegation was reported. Documentation showed the LPN continued to perform neurological checks on the resident and remained in the building until the end of the shift, contrary to facility policy requiring immediate suspension and removal of the accused staff member. Additionally, the facility did not consistently report alleged violations to the state survey agency or notify the Administrator as required. In several incidents involving resident-to-resident altercations or injuries of unknown origin, there was no evidence of timely reporting, comprehensive documentation, or assessment of all involved parties. The lack of thorough investigations and failure to follow established protocols affected multiple residents with varying degrees of cognitive impairment and complex medical histories.