Failure to Notify Guardian of Abuse Allegation and Investigation Findings
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment about an allegation of abuse and the subsequent investigation findings. The resident, who had diagnoses including anxiety disorder, depression, personality disorder, and unspecified psychosis, was under a court-appointed permanent guardianship due to incompetency and was subject to an involuntary order to treat with psychotropic medications. The resident's care plan specifically required that the physician and guardian be notified of any change in condition, including medication non-compliance. Despite this, when an allegation of staff abuse involving the resident was reported and substantiated, there was no documentation that the guardian was informed of either the incident or the investigation results. During the survey, the guardian confirmed in an interview that she had not been notified of the incident or the findings, and this was the first time she was hearing about the event. The facility's policy required that the resident or their representative be informed of any incident and the results of investigations. The DON stated she believed the guardian had been notified but could not provide documentation to support this. The lack of notification to the guardian was confirmed through record review and interviews.