Failure to Report and Investigate Suspected Abuse and Neglect
Penalty
Summary
The facility failed to report and investigate two separate incidents involving suspected abuse and neglect for two residents. In the first incident, a resident with moderately impaired cognition, dementia, and insomnia was found outside in the parking lot near a fire hydrant after eloping from the facility through an emergency door that was not locked. The event was discovered by another resident, who alerted staff. There was no documentation of the event in the clinical record, and required notifications to the family and physician were not completed. The facility did not investigate the elopement or the possibility of neglect, nor did it report the incident as required by policy. In the second incident, a resident with severely impaired cognition, dementia, muscle weakness, and coronary artery disease was physically struck in the back by another resident while attempting to walk past with a walker. Staff witnessed the event and completed witness statements, but the physical abuse was not reported as required. The Director of Nursing confirmed that both the elopement and the resident-to-resident abuse incidents were not reported according to regulatory requirements.