Failure to Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of possible abuse, neglect, or mistreatment involving multiple residents. On the night in question, a CNA observed one resident sitting outside his room, expressing discomfort about entering due to noises and activities occurring inside. Upon checking, the CNA found two other residents alone in the dark room, with one standing against the wall covering his private area. The CNA reported this to the charge nurse, who did not perform a physical or environmental assessment of the residents or the room, nor did she further investigate the situation before escalating the matter to the DON and Administrator. The DON and Administrator arrived at the facility and interviewed the residents involved, all of whom denied any inappropriate behavior or sexual activity. However, no incident report was completed for the event, and there was no documentation of a thorough investigation, including physical assessments or interviews with all potentially involved parties. Staff interviews revealed that the charge nurse did not assess the residents or the environment, and the DON later acknowledged that a complete investigation, including required documentation and assessments, was not conducted. Additionally, the facility's own policies required prompt and thorough investigation and reporting of all alleged violations, which was not followed in this case. The residents involved had significant cognitive and mental health diagnoses, with at least one resident having severely impaired cognition and another with a history of mental illness and behavioral issues. Staff statements indicated uncertainty about the capacity of one resident to consent to sexual activity, and there were conflicting accounts regarding what was heard or observed. Despite these complexities, the facility did not ensure that all required investigative steps were taken, nor did it document the incident or protect residents as outlined in its policies.