Failure to Properly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to properly investigate an allegation of abuse involving a female resident with multiple complex diagnoses, including Moyamoya disease, dysphagia, altered mental status, and conversion disorder with seizures. The incident in question involved a certified nursing assistant (CNA) changing the resident's incontinence brief, during which the resident exhibited signs of pain and distress, such as kicking and banging on the bed. The CNA was heard making a threatening statement to the resident, indicating she would leave the resident in a vulnerable condition if the behavior did not stop. A roommate, who was present and cognitively intact, witnessed the event and later reported not being interviewed as part of the facility's investigation. The facility's investigation was incomplete, as it did not address the verbal statement made by the CNA, failed to interview the eyewitness roommate, and contained inconsistencies regarding the date of the alleged incident. The facility's abuse policy requires thorough investigations, including interviews with all involved persons and witnesses, but these steps were not followed. Additionally, the facility's report did not reflect all relevant details observed in the video evidence or concerns raised by the resident's family member, who had reported the incident and shared the video with the administrator.