Failure to Report and Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, and to report the results of investigations to the proper authorities as required by section 1150B of the Act. Multiple incidents involving residents with severe cognitive impairment, including dementia and Alzheimer's disease, were documented in which allegations of abuse, specifically sexual and physical abuse, were not reported to the state agency or thoroughly investigated. Staff observed and documented inappropriate and abusive behaviors, such as one resident fondling another's breasts and another resident physically assaulting a peer by shoving, hitting, and shaking, yet these incidents were not reported as required. Medical records and staff interviews revealed that residents involved were severely cognitively impaired and unable to protect themselves or communicate effectively. Staff, including CNAs and nurses, witnessed and intervened in abusive incidents, completed internal documentation, and reported events to supervisors. However, these reports did not result in formal investigations or notifications to the state agency. The facility's abuse policy required immediate investigation and reporting of all alleged violations, but this protocol was not followed. The administrator and DON acknowledged that these incidents should have been reported and investigated but were not, often due to the mistaken belief that resident-to-resident incidents involving dementia did not constitute reportable abuse. Further review of records and interviews indicated a pattern of escalating aggressive behaviors by certain residents, repeated staff interventions, and ongoing concerns expressed by staff to management. Despite multiple documented incidents and staff awareness, there was no evidence of completed incident reports, thorough investigations, or state notifications for the abuse allegations. The failure to report and investigate these incidents as required by federal and state regulations constituted a deficiency in the facility's abuse prevention and reporting practices.