Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving five residents. Multiple incident reports documented inappropriate sexual contact between residents, including instances where one resident touched the breast of other residents. Despite these reports, there was no evidence that the facility conducted or documented safety assessments of other residents who may have been affected. Additionally, the facility did not provide or document abuse education for all staff following these incidents, as required by their own policy. Interviews with the DON revealed a lack of awareness regarding the completion of investigation summaries on incident reports and confirmed that staff education on abuse was not formally documented, but only provided verbally. The DON also stated that assessments of potentially affected residents were performed visually and not documented. These actions and omissions resulted in a failure to ensure that all alleged violations were appropriately responded to and thoroughly investigated.