Failure to Identify, Report, and Investigate Abuse and Neglect
Penalty
Summary
The facility failed to identify, report, and investigate multiple incidents of potential abuse, neglect, and mistreatment involving two residents. For one resident, there were repeated documented instances over a period of more than six months where the resident entered female residents' rooms, sometimes while they were sleeping, and engaged in inappropriate behaviors, including verbal altercations and physical contact. Staff notes and interviews confirmed that these behaviors were known to staff, including the DON, social workers, and nursing staff, who routinely redirected the resident but did not initiate a formal investigation or report the incidents to the appropriate authorities. The care plan for this resident acknowledged inappropriate sexual behaviors, but interventions were limited to redirection and monitoring, without escalation or reporting as required by policy. In addition, the facility failed to recognize and report allegations of neglect related to pain management for another resident. Family members made multiple complaints to staff and the DON regarding the resident's unmanaged pain and delayed administration of PRN medication. Documentation showed that these complaints were not entered into the facility's grievance or concern logs, nor were they reported to state agencies as required by the facility's own abuse and neglect policy. Staff interviews confirmed awareness of the complaints but acknowledged that no formal reporting or logging occurred. The facility's inaction included not interviewing potentially affected residents, not investigating the incidents, and not addressing the issues in Quality Assurance meetings. The Administrator confirmed that the facility did not consider the incidents reportable because no formal complaints were received from residents, despite clear evidence of repeated inappropriate behaviors and family-reported concerns. The failure to report, investigate, and implement interventions to prevent further abuse and neglect constitutes a deficiency in the facility's responsibility to protect residents from abuse, neglect, and mistreatment.