Failure to Report and Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
A deficiency was identified when the facility failed to report an allegation of abuse involving two residents with severe cognitive impairment. Both residents had diagnoses including dementia and Alzheimer's disease, and their care plans indicated significant cognitive and decision-making deficits. On the date of the incident, one resident was found standing next to their bed pulling up their pants, while the other was lying on the same bed with their pants and brief down. Both residents were unable to provide details about the incident due to their mental status and medical history. Despite the circumstances and the residents' inability to consent or recall the event, no assessment was completed for one of the residents following the incident, and the event was not reported to the appropriate authorities as required. Staff interviews confirmed that the incident was observed and reported internally to the charge nurse, but facility leadership determined there was no contact and therefore did not initiate a report or further assessment. Additionally, a subsequent similar incident occurred, and again, the response was limited to internal notification without external reporting or immediate resident protection measures. A review of the facility's Abuse, Neglect, and Exploitation policy indicated that any suspected abuse must be reported and investigated immediately, especially when residents may lack the capacity to consent. However, there was no documentation of a report to authorities or a completed investigation for the incidents involving these two residents. The administrator confirmed that the event was not considered reportable, and no body assessment was performed, contrary to facility policy and regulatory requirements.