Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse, resulting in deficiencies in their response to both a sexual abuse allegation and a physical abuse incident. In the first case, a resident with severely impaired cognition and non-verbal status was allegedly inappropriately touched by her boyfriend, as witnessed by a CNA who heard the resident screaming. The CNA intervened and reported the incident, and the nurse on duty notified the nursing home administrator (NHA) and the police. However, the investigation did not include a direct interview with the witnessing CNA to clarify what was observed, nor was there documentation of an interview with the alleged assailant or evidence that the assailant was restricted from the facility during the investigation. Additionally, there was no documentation of staff education or interventions to ensure the resident's safety while the investigation was ongoing. The resident's capacity to consent to sexual activity was not assessed until after the incident, and despite a determination that the resident could not consent, effective interventions were not implemented to prevent a subsequent incident with the same individual. In the second incident, the facility failed to thoroughly investigate a physical altercation between two residents. The investigation did not specify whether any of the interviewed staff had witnessed or overheard the altercation, and there was no documentation that either resident involved was interviewed to understand the circumstances leading to the incident. The assistant director of nursing (ADON) conducted staff interviews, but these were not specific to the incident, and the NHA did not document attempts to obtain statements from the residents involved. Immediate interventions, such as placing stop signs to prevent further altercations, were mentioned, but the investigation lacked comprehensive documentation and failed to substantiate the abuse based on available statements. Both incidents demonstrate a lack of thoroughness in the facility's investigative process, including incomplete interviews, insufficient documentation, and failure to implement or document effective interventions to ensure resident safety during and after the investigation. The facility's actions did not align with its own policy, which requires immediate and comprehensive investigation of all abuse allegations, including interviews with all involved parties and thorough documentation.