Failure to Thoroughly Investigate and Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report two separate allegations of abuse involving two residents. In both cases, the facility did not identify the specific timeframe when the alleged abuse occurred and did not notify local law enforcement in a timely manner. The investigation documentation was incomplete, lacking essential details such as the date and time of the incidents, and there was no immediate notification to the abuse coordinator by the staff who witnessed or were aware of the alleged abuse. The facility's self-reporting template and investigation report reflected missing or delayed information, and the police were not promptly notified, with no case number or documentation initially provided. The first resident involved was an elderly female with diagnoses including depression, dementia, epilepsy, blindness in one eye, and cognitive communication deficit. She required substantial assistance with activities of daily living. The second resident was an elderly male with severe dementia, hemiplegia, seizures, diabetes, and a history of agitation and combative behavior, requiring total staff assistance for toileting and hygiene. Both residents were the subjects of allegations that a staff member had either put soap in the female resident's eyes or physically restrained and verbally abused the male resident during care. Multiple staff members witnessed or were aware of these incidents but delayed reporting them due to fear of retaliation from the accused staff member. Interviews with staff revealed that the incidents were not reported immediately as required by facility policy and regulatory expectations. Staff cited fear of the accused staff member, who was known for making threats, as the reason for the delay. The facility's abuse coordinator and administrator were not informed until days after the incidents, and the subsequent investigation was hampered by the lack of timely reporting and incomplete information. The facility's failure to promptly and thoroughly investigate and report the allegations, as well as to notify law enforcement, constituted a deficiency in responding appropriately to alleged violations of abuse and neglect.