Inadequate Investigation of Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of inappropriate conduct by one resident towards another. Resident 1 reported that Resident 2 entered her room and touched her private parts, an incident confirmed by video surveillance. Despite this confirmation, the facility did not interview other residents to determine if Resident 2 had a pattern of entering other residents' rooms, which was a critical oversight in the investigation process. Resident 1, who had intact cognitive skills, reported the incident to multiple staff members, including a registered nurse and a certified nursing assistant, but felt that her claims were not taken seriously. The video footage showed Resident 2, who had moderate cognitive impairment and lacked decision-making capacity, entering and exiting Resident 1's room multiple times on the night of the incident. Despite this evidence, the facility's investigation was limited to interviews with the involved residents and their roommates, neglecting to gather information from other potentially affected residents. The Director of Nursing acknowledged that the investigation was not thorough, as it did not include interviews with all interviewable residents to check for similar incidents. This failure to conduct a comprehensive investigation could lead to unrecognized acts of abuse, as the facility's policy requires prompt reporting and thorough investigation of abuse allegations. The deficiency highlights a significant gap in the facility's response to allegations of abuse, as they did not fully adhere to their own policies and procedures.
Plan Of Correction
Investigate / Prevent / Correct Alleged Violation CFR(s): 483.12(c)(2)-(4) Corrective action: On 3/20/25 the Administrator reviewed video footage for other random nights (3/7/25 and 3/16/25) with DHS Surveyor and there was no evidence of resident 2 entering into any other resident's room. In addition, on 3/22/25, the Administrator and DON reviewed video footage on additional evenings (3/10/25, 3/12/25 and 3/14/25) and there was no evidence of any resident entering another resident's room. How to identify potentially affected other: On 3/25/25 all Department managers interviewed the Resident assigned to their ambassador rounds asking if another resident and specifically describing profile of Resident 2 entered their room. There was no other resident who entered their room. SSD and DON interviewed all current residents from room 1-26 on 3/25/25 and there was no other resident affected from the same deficient practice. Based on the Department Managers interview as well as preview of video surveillance, no other Resident was affected by this concern. Measures/Systemic change: The Administrator was given 1:1 in-service by Governing Board Member on 4/6/25 regarding Abuse Investigation giving emphasis on conducting thorough investigation to include interviewing other residents. The DON was given 1:1 in-service by the Administrator on 4/7/25 regarding Abuse Investigation giving emphasis on conducting thorough investigation to include interviewing other residents. The Administrator gave in-service to Department Managers on 4/7/25 regarding Abuse Investigation, giving emphasis on conducting thorough investigation to include interviewing other residents. On 4/9/25 the SOC 341 was updated that includes steps to follow for immediate action, SOC 341 Forms, Interview Forms, Local Law enforcement number and Cover sheets for CDHP and Ombudsman for reporting. On 4/9/25 and 4/10/25 DON gave in-service to the Department Manager regarding the SOC 341 Binder in case they will be the assigned Manager of the Day for the weekend. On 4/9/25 DON gave in-service to RN supervisor regarding the SOC 341 Binder giving emphasis on immediate action and steps to do during alleged abuse incidents giving emphasis on interviewing alleged victim, alleged abuser, roommates and other residents who are involved and or affected with the incident within 24 hours of the incident. The Administrator and or designee will review any video footage as necessary within 72 hours of the incident. Other Residents who are affected and or involved with the incident will be interviewed by the Administrator and or Designee within 5 days of investigation. The Administrator and or designee will provide a written report of the results of all abuse investigation and appropriate action taken to CDPH or local laws within 5 working days of the reported allegation. Monitoring: When there is an alleged abuse incident, the Supervisor will conduct thorough interviews with staff, residents involved as well as other residents that could have been affected by the allegation. The Administrator and DON will utilize available equipment and tools to investigate thoroughly. Results will be documented, discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completion Date: 4/10/25