Failure of Governing Body to Ensure Effective Abuse Investigation and Reporting
Penalty
Summary
The facility's governing body failed to establish and implement effective policies for the management and operation of the facility, resulting in inconsistent communication between the governing body and the Administrator regarding regulatory compliance. During the abbreviated survey, three Immediate Jeopardy deficiencies were identified in the areas of Free from Abuse and Neglect, Reporting of Alleged Violations, and Investigate/Prevent/Correct Alleged Violations. The facility's QAPI plan outlined a systematic approach to quality assurance and performance improvement, but this was not effectively executed, as evidenced by the handling of multiple incidents involving potential abuse. Specifically, incidents involving several residents were investigated by the DON, who relied on staff and family interviews to rule out abuse, and did not report these incidents to the state health department because they did not believe abuse had occurred. The Administrator was not consistently notified of incidents in a timely manner and did not sign off on investigations, relying instead on verbal updates from the DON. Additionally, the Administrator did not assess the mental health of involved residents, citing role overlap and lack of responsibility. These actions and inactions led to a failure to ensure proper investigation, reporting, and prevention of abuse as required by regulation.