Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to comply with its abuse prohibition policy by not notifying the State Agency after potential abuse concerns were identified, not investigating allegations of potential abuse, and not submitting the results of any investigation within the required five business days. According to the facility's policy, any suspected or alleged abuse, mistreatment, or neglect must be reported to the appropriate authorities within two hours if serious bodily injury is involved, and an investigation must be initiated within 24 hours. However, documentation and interviews revealed that these steps were not followed after concerns were raised about a staff member being rough with a resident and causing pain to the resident's shoulder. A resident, who was found to be cognitively intact based on a Brief Interview for Mental Status (BIMS) score of 12 out of 15, reported being physically abused by a staff member, resulting in ongoing pain. The resident's representative and an Adult Protective Case Worker confirmed that the facility administrator was made aware of the allegations. Despite this, there was no evidence in the clinical record or incident reports that an investigation was conducted or that the incident was reported to the State Agency as required. The Market Lead Clinical Specialist also confirmed these failures during the survey.