Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency as required, affecting four residents out of five reviewed for abuse. In one incident, a resident with impaired cognition sustained facial burns after another resident threw coffee at him. The incident was documented in the medical record, and the resident was treated with Silvadene cream, but there was no documentation regarding how the burns occurred, and the event was not reported to the state agency. Interviews with staff and administration confirmed that the incident was not reported, and the responsible parties for the injured resident were not notified. Another incident involved a resident being verbally abused and allegedly hit by his roommate. Staff observed verbal abuse and were informed by a visitor about physical abuse. The staff assessed the resident and questioned both parties, but when both denied the incident, no further investigation was conducted, and the event was not reported to the state agency. The administration acknowledged that the resident who was allegedly abused had cognitive impairment and that further investigation and reporting should have occurred. Review of facility policy indicated that all allegations of abuse, neglect, or misappropriation should be reported to the state agency and thoroughly investigated. However, the facility did not submit self-reported incidents for these events and did not conduct thorough investigations as required by policy. This deficiency was identified during the investigation of a specific complaint.