Failure to Conduct Thorough Abuse Investigation and Resident Assessment
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving an alert and cognitively intact resident with chronic kidney disease, spinal stenosis, hypertension, and hyperlipidemia. The resident reported to the night nurse that a CNA was verbally inappropriate, treated her roughly during incontinence care, and threatened her not to use the call light. The nurse notified the administrator, who directed the CNA to leave the facility and performed a body check, noting no visible injuries. However, there was no documented assessment of the resident's psychosocial well-being or further physical assessment after the incident. The internal investigation was incomplete, as the administrator did not obtain written statements or conduct interviews with all relevant staff, including the night supervisor and the CNA involved in the incident. Other staff members working during the CNA's shift were not interviewed, and the Director of Nursing was not informed or involved in the investigation. Additionally, the facility did not attempt to interview other residents who may have been affected by the alleged abuser, despite having access to a list of residents cared for by the CNA on the night of the incident and previous shifts. Facility policy requires a comprehensive investigation, including interviews with all relevant staff, witnesses, and potentially affected residents, as well as thorough documentation and assessment of the alleged victim. The investigation did not meet these requirements, as key interviews and assessments were omitted, and there was a lack of documentation regarding communication with the resident's family, physician, or medical director.