Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into three separate allegations of abuse involving two residents. According to the facility's own policy, all reports of abuse, neglect, exploitation, or misappropriation are to be reported to appropriate agencies and thoroughly investigated, with findings documented and reported. However, documentation revealed that when one resident reported to a Certified Occupational Therapy Assistant (COTA) that an employee had inappropriately touched them during incontinence care, the facility did not recognize or investigate this as an allegation of sexual abuse. Additionally, another resident reported to the same COTA that the same employee had opened their house dress without reason, looked at them, and ran his hand up and down their body, which was not thoroughly investigated. The roommate of this resident also reported that the employee pushed and shoved the resident during a transfer, but again, no thorough investigation was conducted. The review found that no witness statements or interviews of staff or residents were completed for these allegations. Furthermore, there was no documented assessment of one resident after the abuse allegation was made, and neither the physician nor the family was notified. The Nursing Home Administrator confirmed that the investigations were incomplete and did not meet the facility's policy requirements. These failures were cited under multiple Pennsylvania Codes related to management, resident rights, and nursing services.