Failure to Timely Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, and/or mistreatment were reported immediately, as required by law and facility policy. Specifically, an incident involving a resident with severe cognitive impairment and other residents was not reported to the state or investigated further, despite multiple staff being aware of allegations of possible sexual abuse or inappropriate behavior. The incident was not documented in the facility's incident and accident reports, and no formal investigation was initiated at the time of the event. The resident at the center of the incident had a history of dementia, cognitive communication deficit, bipolar disorder, alcohol-induced persisting dementia, and depression, with a severely impaired BIMS score indicating significant cognitive impairment. On the night in question, staff observed unusual behavior: one resident refused to enter his room, reporting hearing noises and expressing discomfort, while another was found standing in the dark with his hands over his private area. Staff reported the situation to the charge nurse, who then notified the DON and Administrator. However, neither the charge nurse nor other staff performed a physical assessment or thorough investigation of the residents involved at the time. Interviews revealed that staff and residents provided conflicting accounts, with some staff expressing concern that the incident should have been investigated as possible abuse, especially given the cognitive status of the resident involved. Despite these concerns and the facility's own policies requiring immediate reporting and investigation of such allegations, the DON and Administrator decided not to report the incident to the state, citing denials from the residents involved. The lack of timely reporting, assessment, and documentation constituted a failure to follow both regulatory requirements and the facility's abuse prevention and reporting policies.