Failure to Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident verbal abuse involving a resident with multiple diagnoses, including dementia with agitation and violent behavior. The resident's care plans documented ongoing behavioral challenges and interventions, and the Minimum Data Set assessment indicated moderately impaired cognitive skills and recent physical and verbal behaviors toward others. On the date of the incident, there was no documentation in the resident's medical record regarding the alleged event between the resident and a CNA, nor was there a self-reported incident (SRI) submitted for this occurrence. Personnel records showed that the CNA involved was terminated for threatening to physically harm the resident, with witness statements from other staff members corroborating the use of threatening and profane language. However, the facility's investigation lacked critical components: there was no evidence of an interview or written statement from the alleged perpetrator, no statement from another CNA present during the incident, and a missing additional statement from a witness. Interviews with staff and the resident confirmed the occurrence of yelling, cursing, and threats, but the facility did not provide further documentation or evidence of a comprehensive investigation. The facility's policy required immediate reporting of abuse allegations, assessment of the resident, notification of the physician and resident representative, removal of the accused staff member, and documentation in the medical record. Despite these requirements, the facility did not follow through with the necessary investigative steps or documentation, resulting in a failure to appropriately respond to and investigate the alleged abuse incident.