Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated and reported as required. 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. The event was not reported to the state agency, and the responsible parties were not notified. Interviews with staff confirmed that the incident was not thoroughly investigated or reported as required by facility policy. Another incident involved a resident being verbally abused and allegedly hit by his roommate. Staff observed verbal abuse and were later informed by a visitor that physical abuse may have occurred. 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 resident who was allegedly abused had severely impaired cognition, which was not taken into account during the investigation. Review of facility policy indicated that all allegations of abuse should be reported and thoroughly investigated. However, in these cases, the facility did not follow its own policy, as multiple incidents involving resident-to-resident abuse were neither reported to the state agency nor thoroughly investigated. This deficiency affected four residents out of five reviewed for abuse, as documented in the survey findings.