Failure to Prevent, Investigate, and Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as to ensure proper investigation and reporting of such allegations. Specifically, the facility did not ensure the safety of two residents after they made serious allegations against each other and a staff member. One resident, who was paralyzed and required significant assistance with activities of daily living, alleged that the Administrator (ADM) harassed, bullied, and picked on him. Despite this, there was no documentation of the allegation in the resident's records, no investigation was initiated, and no interventions were implemented to ensure his safety. Staff interviews revealed confusion about the process for handling such allegations, and the ADM, who was also the abuse and neglect coordinator, stated he was not aware of the allegation and had not investigated it. Another resident, who was cognitively intact but had a history of manipulative and impulsive behaviors, alleged that the first resident threatened her with sexual violence. She called the police non-emergency line, and law enforcement responded, instructing both residents to stay away from each other. However, the facility did not document the incident, offer a room change, or implement any interventions to separate the residents or ensure their safety. Both residents continued to reside on the same hallway, and staff did not monitor or document any follow-up actions related to the allegations. Progress notes, assessments, and the facility's incident log contained no entries regarding these events. Interviews with various staff members, including the DON, HR, SW, and CNAs, revealed a lack of clarity and training regarding the reporting and investigation of abuse, neglect, and exploitation (ANE). Staff consistently identified the ADM as the abuse and neglect coordinator responsible for reporting and investigating ANE, but there was no evidence that the required steps were taken in response to the allegations. The facility also failed to remove the alleged perpetrator from the environment upon notification of the allegations, and there was no documentation of any investigation or reporting to the appropriate authorities. This lack of action and documentation placed residents at risk of further abuse, neglect, or harm.