Failure to Timely Investigate Abuse Allegation and Resident Fall
Penalty
Summary
The facility failed to investigate a potential case of abuse and did not investigate a fall in a timely manner for two residents. One resident, admitted with unsteadiness on feet and a traumatic brain injury, experienced an unwitnessed fall while attempting to go outside. The investigation into this fall was not completed until nearly two weeks later, despite facility expectations that such investigations be completed within five days. Another resident, admitted with a history of stroke, anxiety, and significant cognitive impairment, was diagnosed with trichomonal vaginitis, a sexually transmitted infection, after presenting with persistent symptoms and being sent to the emergency department. Despite the diagnosis and a public complaint alleging a sexually transmitted disease, there was no documentation in the clinical record of an investigation into potential sexual abuse for this resident. Staff confirmed that an investigation into possible sexual abuse was expected but not completed.