Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident, identified as Resident 1, who had chronic kidney disease, chronic heart failure, and an anxiety disorder. The resident reported being hit on the head and dragged by two staff members, whom she described as 'two black girls,' and stated she could identify one if seen again. Despite this, the facility did not take adequate steps to identify the alleged perpetrators or obtain witness statements from nursing staff. The facility's investigation documentation was insufficient, lacking any evidence of attempts to verify the resident's claims or protect her during the investigation. The facility's policy required immediate and thorough investigations of abuse allegations, including obtaining signed statements from the resident, witnesses, and the accused. However, the facility did not follow these procedures. The Assistant Director of Nursing confirmed that no investigation or witness statements were obtained, and the resident was not asked to identify the alleged perpetrators, despite providing a description. The facility's failure to suspend any staff members during the investigation further compromised the resident's safety. The Nursing Home Administrator acknowledged that the facility did not thoroughly investigate the allegations and confirmed that the resident was not asked to identify the alleged perpetrators. The facility's electronic health record system was unable to retrieve past 24-hour reports, hindering the investigation process. The lack of a comprehensive investigation and failure to protect the resident during the investigation period resulted in a deficiency in meeting the regulatory requirements for investigating and preventing abuse.
Plan Of Correction
1. A thorough investigation has been completed for R1's allegations to include written witness statements of nursing staff. R1 was interviewed by the Executive Director on 2/3/25 and confirms feeling safe in the facility. 2. The Executive Director/designee will review 24-hour report and physician/other practitioner progress notes over last 7 days to ensure that there are no unreported allegations of abuse. In addition, an audit will be conducted on any allegations occurring over the last 7 days to ensure thorough investigations are in place. 3. Licensed staff will be re-educated by the Executive Director on the facility's abuse policy which includes recognizing documentation that constitutes initiation of the facility's abuse policy, and on the steps for an immediate, thorough investigation to include interviewing and obtaining signed statements from any witness or individual who has knowledge of the alleged incident. 4. Weekly audits of abuse investigations will be conducted by the Executive Director or Designee x 3 months to validate thorough investigations have been completed to include immediate measures implemented to protect resident safety, identification of perpetrator, if able and written statements are in place. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or recommendation.