Failure to Document Thorough Abuse Investigation
Penalty
Summary
The facility failed to maintain evidence that an allegation of abuse was thoroughly investigated for two residents. One resident, who had a history of stroke, physical debility, and moderate cognitive impairment, reported that another resident, who was cognitively intact and independent in mobility, entered her room without permission and attempted to touch and kiss her inappropriately. The incident was witnessed by three CNAs, who intervened and removed the alleged perpetrator from the room. The reporting nurse, Weekend Supervisor (WS) 8, documented the incident in the residents' medical records and notified the Executive Director, Director of Nursing, and the police department. Both residents were placed on one-on-one supervision following the incident. Despite these actions, the facility's investigation file for the incident did not include a written statement from WS 8, who was the staff member in charge and had direct knowledge of the event. The Corporate Executive Director confirmed that while WS 8 had made progress notes in the medical records, there was no separate written statement included in the investigation file. The facility's abuse policy requires that statements be taken from individuals witnessing the incident and from the staff member to whom the initial report was made, but this documentation was missing from the investigation file.