Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with a history of mild cognitive impairment, personality disorder, delusional disorders, unspecified psychosis, and depression. On the date in question, the resident's sister contacted local law enforcement to report concerns that the resident was being abused and did not feel safe. Law enforcement arrived at the facility to address the allegation. Facility documentation showed that staff were aware of the report and notified relevant parties, including the resident's guardian, Adult Protective Services social worker, and supervisory staff. However, there was no documentation of any investigation into the abuse allegation as required by facility policy. During an interview, the Director of Nursing stated that both the resident and the resident's sister had made multiple prior unfounded allegations of abuse and, as a result, did not believe this particular allegation warranted reporting or investigation. The facility's policy requires that all reports of abuse, neglect, or mistreatment be promptly and thoroughly investigated, but this was not followed in this instance. No root cause investigation or analysis was documented for the reported allegation.