Failure to Interview Other Cognitively Intact Residents During Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a cognitively intact resident who reported verbal abuse and neglect by a CNA. The resident, who had a history of Atrial Fibrillation and Anxiety Disorder and was assessed as cognitively intact with a BIMS score of 15, alleged that after returning to her room and activating her call light for assistance, the CNA turned off the call light without providing help and later made dismissive remarks about being short-staffed and needing a break. The incident was discovered when the Activities Director found the resident crying in her room. Despite the facility's abuse policy requiring resident statements as part of the investigation, the written investigation did not include interviews with other residents who received care from the same CNA, particularly those with a BIMS score of 13 or higher who could have provided relevant information. The Administrator, DON, and Social Services Director all confirmed that they did not interview other cognitively intact residents assigned to the CNA during the shift, and the Administrator also acknowledged that surveillance video was not reviewed until after the state agency's entrance.