Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to complete a thorough investigation and report the results of all investigations to the State Survey Agency within five working days of the incident for two residents reviewed for abuse. According to facility policy, any allegation of abuse must be reported immediately and investigated promptly, with results completed within five working days. However, in the case involving two residents, the facility did not follow these procedures after an incident where one resident was found on top of another in bed, which was considered an allegation of sexual abuse. Medical record reviews revealed that one resident had severe cognitive and physical impairments, including dementia, delirium, and blindness, while the other had moderate cognitive impairment and a history of physical behaviors toward others. The incident was reported to the Administrator and Director of Social Services, who responded after the residents were separated. The investigation conducted by the facility was incomplete, containing only one written staff statement and lacking documentation of a physical assessment for the resident involved, as well as missing incident reports for both residents. Further review showed that there was no documentation in the progress notes by the Abuse Coordinator regarding the incident, nor any follow-up note explaining the room change for the affected resident. Interviews with facility staff confirmed that the investigation did not include statements from all staff who witnessed the event, and the incident was not reported to the state agency as required. The lack of a comprehensive investigation and timely reporting constituted a failure to comply with both facility policy and federal regulations.