Failure to Investigate and Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of two separate allegations of abuse involving two residents. In the first incident, a resident with moderately impaired cognition and diagnoses including dementia and insomnia was found outside the facility in the parking lot near a fire hydrant after eloping through an emergency door that was not locked. Documentation of the event, including notification to the family and physician, was missing from the clinical record, and the facility did not investigate the elopement or report it as required by policy. Staff and resident interviews confirmed the resident's exit through the emergency door, which was used for supply deliveries and was not secured at the time. In the second incident, another resident with severely impaired cognition and multiple diagnoses, including dementia and muscle weakness, was physically struck in the back by the first resident while in the dining room. Staff witnessed the event and completed two witness statements, but the physical abuse was not reported as required, and the facility did not follow its written policies and procedures for investigating abuse. The Director of Nursing confirmed that the facility failed to ensure a complete and thorough investigation in both cases.