Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policy after an allegation of abuse involving a cognitively impaired resident. Resident C had diagnoses including Alzheimer’s disease, dementia, seizures, weakness, and depression, and required substantial assistance with most activities of daily living. Her care plan documented a preference for video recording in her room and a STOP sign across the door frame, with interventions to protect privacy. On one reported incident date, a male resident entered her room and sat on her bed; the facility’s incident report documented that Resident C reported no physical contact and that a head‑to‑toe assessment showed no findings. However, Resident C’s responsible party later provided an email describing an earlier incident captured on family-installed room cameras in which the same male resident entered Resident C’s room while she was asleep, attempted to sit on the bed, opened and closed his robe, and then sat in a chair. The email further described that the male resident then moved back to the bed, sat on the bed, and then sat directly on Resident C’s chest and left shoulder, causing her to groan and call out in pain, before he sat on the floor next to the bed and fell asleep until staff found him and escorted him out. This allegation was reported by the responsible party to the previous Administrator via email as a follow-up to an incident she had already reported. The current Administrator later acknowledged awareness of this abuse allegation and that a thorough investigation had not been completed by the previous Administrator. The facility’s written policy required that all alleged violations reported by residents or relatives be immediately reported to the Administrator and the Department of Health and that, once notified, an investigation of the alleged violation be conducted. Surveyors determined that the facility failed to implement this policy by not conducting a thorough investigation into the abuse allegation involving Resident C.
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