Failure to Interview Key Witness in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents who had a verbal and physical altercation in their shared room. According to the facility's policy, all individuals who may have knowledge of the incident, including those in the vicinity at the time, should be interviewed as part of a comprehensive investigation. However, the facility's investigation file showed that only the involved residents and staff were interviewed, and the roommate who was present in the room during the incident was not interviewed. This omission was confirmed through interviews with the Social Services Director (SSD) and the Administrator, both of whom indicated that they did not see the need to interview the roommate. Further review revealed that the roommate, when later interviewed by surveyors, stated he was present in the room during the altercation, heard the commotion, and could provide relevant information about the incident, even though his curtain was closed. The facility's failure to interview this roommate, as well as other potentially affected residents, resulted in an incomplete investigation of the abuse allegation, contrary to the facility's own policies and procedures.