Failure to Investigate and Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was investigated and reported as required for one resident. The facility’s Abuse and Neglect policy, dated 09/12/25, required immediate reporting of allegations, suspicions, or incidents of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown source involving residents. Resident #1 was admitted on 12/05/25 with a diagnosis of congestive heart failure, and the admission assessment documented intact cognition with a BIMS score of 15. A skilled assessment on the same date identified bruises on the resident’s right lateral thigh, left inner thigh, and near the rib cage. On 12/05, an APS investigator came to the facility and informed staff they were there to investigate an allegation of abuse for Resident #1. The DON later reported that a meeting was held regarding this allegation, attended by the Administrator, DON, ADON, and Skilled Nurse Manager, during which they discussed and investigated the bruising and concluded it was caused by a lift sling and not abuse. Based on this internal conclusion, they decided not to report or further investigate the allegation of abuse. The Administrator reported that APS had informed them they were conducting an investigation concerning an allegation of abuse for the resident, and acknowledged they believed they did not have to report the allegation because APS is part of a state agency, despite the facility policy requiring immediate reporting and investigation.
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