Failure to Investigate and Report Resident's Allegation of Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation following an allegation of physical abuse made by a resident against two staff members. The resident, who had diagnoses including Parkinsonism, muscle wasting, quadriplegia, and depression, reported to the Administrator via text that staff had physically fought with her during a transfer, despite her repeated requests to wait for the next shift for personal care. The resident described the incident as traumatizing and characterized the staff's actions as physical abuse, stating that her requests were ignored and that she was grabbed against her will. Interviews and record reviews revealed that the Administrator, who also served as the abuse coordinator, received the resident's allegation but did not initiate an investigation or report the incident to the required agencies as outlined in the facility's policies. The Administrator acknowledged that the incident should have been considered abuse and that an investigation should have been started, but confirmed that no investigation was conducted. Staff interviews further indicated that the policy required immediate reporting and suspension of accused employees, but these steps were not taken. The Director of Staff Development and other staff also confirmed that the incident met the criteria for abuse and should have been reported and investigated. Documentation showed that the resident's allegations were communicated to the Administrator and other staff, but there was no evidence of timely reporting to law enforcement, the ombudsman, or the state agency, nor was there evidence of employee suspension or notification of investigation results to the resident. The facility's failure to respond appropriately to the abuse allegation left the resident at risk for further abuse and did not comply with established policies for abuse reporting and investigation.