Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the state agency, as required by policy. One resident with dementia and moderate cognitive impairment was documented in a psychiatric progress note for inappropriately attempting to kiss another resident, and staff were instructed to redirect him and keep him away from vulnerable patients. However, there was no care plan addressing sexual inappropriateness for this resident prior to a later date. Another resident, who was severely cognitively impaired and dependent on staff for mobility, was reported by a family member to have been touched inappropriately by the first resident. This information was relayed to a unit manager and a certified medication aide, but neither the social worker, DON, ADON, nor the administrator were made aware of the allegations or the incident documented in the psychiatric note. As a result, the facility did not investigate the incidents or implement interventions to prevent further occurrences. The lack of reporting and investigation allowed the inappropriate behavior to continue, as there was no documentation of actions taken to address the situation. The facility's policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities, but this protocol was not followed in these cases.