Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse, protect residents during the investigation, and report the results of the investigation as required by state law. A resident with a history of major depressive disorder, anxiety, mood disorder, and schizophrenia, and with severely impaired cognition, reported that a nurse hit her while she was in the shower. The facility did not initiate an immediate investigation or implement protective measures for the resident or others while the allegation was being reviewed. Documentation showed that the resident became agitated during a shower, called staff names, threw objects, and refused assistance, eventually lying naked on the floor and repeatedly requesting to be sent to the hospital. Staff were unable to examine her for injuries or obtain vital signs due to her refusal to be touched. The nurse contacted the medical director, who ordered the resident to be sent to the hospital for further evaluation. There was no evidence that the facility conducted a thorough investigation into the abuse allegation or took steps to prevent further potential abuse during this period. Interviews with staff and review of facility records revealed that the required Post-Incident Report (PIR) and other investigation documentation were missing. The DON and administrator were unable to provide the PIR or any additional investigation records, citing that the previous administrator had not left the necessary paperwork. The facility's own abuse policy requires immediate reporting, thorough investigation, and documentation of all findings, none of which were completed or available for review in this case.