Failure to Accurately Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy by not accurately and promptly reporting an allegation of abuse involving a resident with multiple psychiatric and cognitive diagnoses. An incident was self-reported in which a resident alleged that an LPN spoke to her in an aggressive and inappropriate manner, making her uncomfortable. The facility's investigation was compromised by errors in documentation, including listing the wrong staff member as the alleged perpetrator and copying incorrect information into the self-reported incident (SRI) report. Additionally, the allegation was not immediately reported to the appropriate personnel as required by facility policy. In a separate incident, the facility did not thoroughly investigate an allegation of physical abuse between two residents, both with significant psychiatric and cognitive conditions. Documentation revealed that one resident pushed another, but the investigation lacked statements from the involved residents and did not clarify the sequence of events. Key witness statements and nursing notes were not included in the initial investigation materials provided to surveyors, and there was uncertainty about when and to whom the incident was reported. The facility's records were inconsistent, and the investigation did not fully address the reported physical altercation. Both incidents demonstrate failures in following the facility's abuse, neglect, and exploitation policy, which requires immediate reporting and thorough investigation of all allegations. The deficiencies included delayed reporting, inaccurate documentation, and incomplete investigative records, affecting multiple residents reviewed for abuse.