Failure to Timely Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse in a timely manner for a resident with severe cognitive impairment, as required by its own policy. The policy mandates that an immediate investigation is warranted when there is suspicion or report of abuse, neglect, or exploitation, and outlines specific procedures for such investigations. Despite this, the facility did not initiate an investigation until nine days after staff first became aware of the allegation. The resident involved had diagnoses including dementia, heart failure, and a mixed receptive-expressive language disorder, and was assessed as having severe cognitive impairment. Multiple staff members, including a CNA, RN, social worker, and MDS coordinator, became aware of the resident's or her family's concerns that someone may have sexually abused her. These concerns were communicated to various staff members, but none of them reported the allegation to the facility's Abuse Coordinator or administration as required. The social worker and other staff did not act on the information, partly because the family expressed doubt about the allegation and did not wish to file a complaint. The delay in reporting was only identified after the local police department notified the facility that an allegation had been made and reported to Adult Protective Services. At that point, the facility initiated an investigation, but it was confirmed by the administrator that staff had prior knowledge of the allegation and failed to report or investigate it promptly, resulting in a failure to follow the facility's abuse investigation policy.