Failure to Document and Investigate Alleged Abuse
Penalty
Summary
The facility failed to maintain evidence that allegations of abuse were thoroughly investigated for two residents out of five reviewed. Facility policy requires that all unusual occurrences and alleged violations be thoroughly investigated, with documentation of the investigation, including witness statements, physical assessments, notifications, and incident reports. However, for one resident with severe cognitive impairment and a history of dementia, an allegation of sexual abuse was reported, but there was no documentation of a comprehensive investigation. The only available information was a brief summary from the facility's incident reporting system, with no supporting documentation such as witness statements, social service notes, incident reports, or physical assessments. Interviews with current staff revealed that neither the current DON nor the Case Manager participated in or had knowledge of the investigation, and no records could be located. The former DON, who would have been responsible for the investigation, did not recall the incident and stated that all investigations were left in her desk drawer when she left the facility. A second resident, also with severe cognitive impairment and multiple psychiatric diagnoses, was identified as having an abuse allegation reported to the state agency. Review of the medical record and interviews with facility leadership confirmed that there was no documentation of an investigation for this resident either. The Administrator and DON acknowledged that a thorough investigation should have included interviews, witness statements, physical and skin assessments, and notifications, but were unable to determine what actions, if any, were taken due to the absence of records. The lack of documentation and inability to verify that thorough investigations were conducted for both residents constitutes a failure to respond appropriately to alleged violations as required by facility policy and regulatory standards. The deficiency was identified through review of facility policies, medical records, state intake information, and staff interviews, all of which confirmed the absence of required investigative documentation for the abuse allegations.