Failure to Investigate Abuse Allegations for High-Risk Resident
Penalty
Summary
The facility failed to conduct a formal investigation into multiple allegations of physical and sexual abuse made by a resident with mild cognitive impairment, chronic pain, and a history of behavioral disturbances, paranoia, and delusions. The resident, who required substantial assistance and used a wheelchair, reported on several occasions that he had been struck on the head and touched inappropriately. Documentation shows that staff were aware of the resident's history of making abuse allegations and had implemented a buddy care system as a preventive measure. Despite these safeguards and the resident's repeated reports, staff responses were limited to documentation and internal notifications, without initiating a formal investigation as outlined in facility policy. Interviews with nursing and administrative staff revealed that the decision not to formally investigate was based on the resident's history of making similar allegations, the presence of the buddy care system, and the belief that no other residents could have entered the room. The facility's Vulnerable Adult Abuse Prevention Plan required a review and formal investigation of each allegation, including completion of an Investigation Form and staff interviews. However, these steps were not taken in response to the resident's reports, and the interdisciplinary team determined that a formal investigation was unnecessary, contrary to facility policy.