Failure to Complete and Report Abuse Investigations
Penalty
Summary
The facility failed to ensure thorough investigations were completed and the results reported to the State Agency for four out of eleven sampled residents who were involved in allegations of abuse. In multiple incidents, including verbal abuse between a resident and a staff member, abuse between two residents, and abuse by a resident toward an LPN, the facility did not complete or submit investigations as required. Initial incident reports were sent to the appropriate agency, but no follow-up investigations or results were provided by the facility as of the survey date. Interviews with facility leadership revealed that the investigations were missing, and the reportable investigations binder could not be located within the facility. The administrator and regional nurse confirmed the absence of the required documentation, and the DON stated that investigations should have been submitted by the former SSD but were not. The facility's policy required timely reporting and investigation of abuse allegations, but these procedures were not followed in the cited cases.