Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to timely report and thoroughly investigate multiple allegations of abuse, including sexual, physical, and verbal abuse, involving residents with severe cognitive impairments. Several incidents were not reported to the State Survey Agency within the required timeframes, and law enforcement was not notified in cases of alleged sexual assault. The facility also did not ensure that residents were protected from further potential abuse during the investigation period, as required by their own policies. Staff interviews and record reviews revealed that supervision and interventions for residents with known aggressive or inappropriate behaviors were inconsistently implemented and not maintained to prevent recurrence. One resident with a history of dementia, agitation, and aggressive behaviors was involved in repeated incidents of physical and sexual abuse toward other residents. Despite documented observations and staff reports of inappropriate touching and physical altercations, the facility administration often dismissed these allegations, citing insufficient evidence or the brevity of the incidents as reasons for not reporting or investigating further. Staff statements were inconsistently collected, often unsigned, and the cognitive status of the residents involved was not adequately considered during interviews. In some cases, care plans were not updated to reflect new risks or to implement protective measures for vulnerable residents. The facility's failure to act in accordance with its abuse prevention policies resulted in a pattern of unreported and uninvestigated abuse allegations, leaving residents at continued risk. The lack of immediate protective actions, incomplete documentation, and disregard for staff observations contributed to the finding of Immediate Jeopardy, affecting all residents on the dementia unit. The deficient practice persisted as the facility continued to implement its action plan, but the initial failures were not mitigated during the period under review.