Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and injuries of unknown origin involving several residents. In numerous cases, when allegations were made by residents or their families regarding rough handling, verbal abuse, or unexplained bruising, the facility's investigations were incomplete. Specifically, the investigations often lacked interviews with other residents who may have been under the care of the accused staff members, and in many instances, there were no additional staff interviews conducted to corroborate or refute the allegations. This pattern was observed across a range of incidents, including those involving residents with cognitive impairments such as dementia, who may have been unable to clearly communicate their experiences. For example, in one case, a resident expressed fear and alleged being hit by a GNA, but the facility did not interview other residents or staff to determine if there was a pattern of similar behavior. In another instance, a resident with a history of anxiety and fear of falling was found with bruising, but the facility attributed the injuries to the resident's own actions without conducting further interviews or assessments. There were also cases where residents reported being treated roughly or verbally abused by staff, yet the investigations were limited to statements from the accused staff or the reporting resident, with no broader inquiry into the experiences of other residents or staff on the unit. Additionally, the facility did not consistently assess or interview residents who were non-verbal or cognitively impaired to determine if they felt safe or had experienced similar issues. In several cases, the documentation of the investigation was limited to a few statements or medical notes, and there was a lack of comprehensive review or follow-up. The failure to conduct thorough investigations, including interviews with potentially affected residents and relevant staff, resulted in incomplete assessments of the alleged incidents and did not ensure that all possible concerns were identified and addressed.