Failure to Timely Report and Thoroughly Investigate Abuse, Neglect, and Theft Allegations
Penalty
Summary
Facility staff failed to implement their abuse policy for reporting and conducting thorough investigations in multiple incidents involving five residents. In two cases, staff did not report incidents of abuse within the required two-hour timeframe. Specifically, after a physical altercation between two residents, the incident was not reported to the state survey agency, adult protective services, or the ombudsman until several hours after the event, exceeding the facility's policy and regulatory requirements for timely reporting. The DON confirmed that the facility's process was to report within 24 hours, which contradicted the policy's two-hour requirement for abuse or bodily injury cases. Additionally, the facility did not conduct comprehensive investigations into allegations of abuse and misappropriation of property. In one instance, a resident was assaulted by another resident in the smoking area, but the investigation file lacked statements from staff or all potential witnesses, and only included a single resident's account. Another incident involved a resident being struck in the face by a peer, but the investigation did not include interviews with the victim, the alleged perpetrator, or the staff assigned to supervise. In the case of a resident reporting missing money, the investigation was limited to a brief summary and did not include interviews with staff or attempts to identify witnesses, despite the resident's claim of seeing a staff member near his belongings. The facility's documentation and interviews revealed that required investigative steps, such as collecting evidence and interviewing all involved parties, were not consistently followed. The investigation files provided to surveyors were incomplete, often missing critical witness statements and lacking evidence of a thorough review as outlined in the facility's own policies. These deficiencies were confirmed through interviews with the DON and review of facility records, which showed a pattern of incomplete and delayed responses to allegations of abuse, neglect, and theft.