Failure to Investigate Alleged Abuse Reported by Resident's Proxy
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with cerebral palsy, intellectual disability, and dysphagia, who was cognitively severely impaired and required assistance with activities of daily living. The resident's Health Care Proxy Agent sent an email to the Administrator describing an incident in which a Certified Nurse Aide allegedly yelled at the resident, threatened to withhold food, and stepped on the resident's foot, which was characterized as abuse. Despite receiving this email, the Administrator did not recognize or act upon the abuse allegation, and the Director of Nursing was not informed of the incident. A review of facility policies indicated that all allegations of abuse are to be promptly reported and thoroughly investigated, including notifying the DON and Administrator-on-call, and conducting interviews with involved parties. However, documentation provided by the Administrator did not show evidence of an investigation into the abuse allegation. Interviews with facility leadership confirmed that the required investigation was not initiated, as the Administrator overlooked the abuse allegation in the email correspondence.