Failure to Submit Final Abuse Investigation Reports to State Agency
Penalty
Summary
The facility failed to submit final investigation reports regarding allegations of abuse to the state surveying agency as required by its own Abuse, Prevention, and Prohibition Policy. The policy mandates that any allegation of abuse or neglect be reported to the mandated state agency and that a final report be submitted following an investigation within five business days. However, for two separate incidents where one resident physically assaulted two other residents, the administrator confirmed that while initial reports and investigations were completed, the final investigation reports were not compiled or submitted to the state agency. Additionally, another incident involving a resident kicking another was not investigated, and no final report was sent. The incidents involved residents with significant medical and cognitive impairments, including diagnoses such as dementia with behavioral disturbances, muscle weakness, and major depressive disorder. One resident's progress notes documented a change in condition following a physical altercation, yet no investigation or final report was completed for this event. These failures affected three of five residents reviewed for abuse in the sample and were confirmed through interviews and record reviews.