Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of alleged abuse, neglect, and mistreatment for four out of five residents reviewed. In one case, a resident with severe cognitive impairment was found to have labial bruising and vaginal tears of unknown origin while hospitalized. The facility's investigation did not address discrepancies in transportation times, did not include all relevant staff interviews, and failed to conduct or document comprehensive skin assessments for all residents following the incident. Additionally, the investigation lacked documentation of education or competency checks for transport drivers and did not include interviews with contracted hospice nurses. Another resident, who was cognitively intact, reported not receiving pain medication and assistance despite repeated requests, leading to distress and a grievance report. The facility's documentation did not include interviews with other residents about missed care, education provided to staff, or records of follow-up support. The investigation file was incomplete, and key documentation such as staff interviews and education records could not be located by facility leadership. Additional deficiencies were noted in the handling of a resident's report of neglect and rough care, as well as a verbal altercation between a resident and a family member. In both cases, the facility failed to document thorough investigations, including interviews with involved parties, skin assessments, and staff education. Facility leadership acknowledged during interviews that the investigations were incomplete and lacked supporting documentation, failing to meet the requirements outlined in the facility's own abuse prevention policies.