Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that a male CNA performed pericare in a rough manner, causing pain but no injury. The resident, who was alert and able to communicate, stated that the incident occurred before lunch on a Thursday prior to her discharge, but could not recall the aide's name. The Administrator interviewed the resident and ten staff members who worked with her during the relevant period, but none recalled the event or any complaints. Assignment sheets showed multiple aides worked with the resident, making it difficult to identify the alleged perpetrator. The investigation did not include interviews with other residents who may have been present, as the Administrator stated they were non-interviewable, and there was no attempt to interview responsible parties or families of these residents. Additionally, the facility did not conduct assessments of non-interviewable residents for signs or symptoms of abuse, such as bruising or behavioral changes. The facility's abuse policy lacked guidance on investigating when residents in the area are non-interviewable. As a result, the investigation was incomplete and did not ensure that all residents were protected from potential abuse.