Failure to Report Alleged Abuse to Authorities and Maintain Investigation Documentation
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the appropriate authorities for two residents out of five reviewed in abuse investigations. Facility policy required that all alleged and substantiated incidents of abuse be reported to the Bureau of Quality Assurance of Health Care Facilities and other required agencies. However, for one resident with severe cognitive impairment and a history of dementia, an allegation of sexual abuse was reported internally, but there was no documentation that law enforcement or Adult Protective Services (APS) were notified. The only available documentation was a 5-day follow-up report from the facility's incident reporting system, and the current Director of Nursing (DON) confirmed that no other records or evidence of required notifications existed. Interviews with the current and former DONs revealed a lack of clarity and documentation regarding the investigation and notifications related to the abuse allegation. The former DON, who was responsible for abuse investigations at the time, stated that all investigation documents were left in her desk drawer when she left the facility, but these were not available to the current administration. The current DON attempted to verify notifications with local police and APS, but both agencies confirmed they had no record of being notified about the incident. The facility's administrator also confirmed that there was no documentation to show that the required notifications had been made for either resident involved in the abuse investigations. A second resident, also with severe cognitive impairment and multiple psychiatric diagnoses, had allegations of abuse reported, but again, there was no investigation documentation or evidence that the state agency or APS had been notified. The administrator and DON were unable to determine what the investigations entailed due to the absence of retained documentation from the previous administration. The lack of documentation and failure to notify the appropriate authorities constituted a deficiency in the facility's handling of abuse allegations.