Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with significant cognitive deficits, as evidenced by a BIMS score of 00 and a care plan noting risk factors for abuse. The incident began when the resident's wife, a retired nurse and mandated reporter, observed a severe bruise near the resident's eye and reported that the resident claimed a man had entered his room and caused the injury. The facility's abuse prevention policy requires interviews with the person reporting the incident, anyone with direct knowledge, the resident if possible, and other residents and staff who may have relevant information. During the investigation, staff who worked the night of the alleged incident were interviewed and reported not seeing any male enter the resident's room. However, the investigation did not include interviews with other residents residing near the affected resident's room or those who received care from the same staff. The Director of Nursing confirmed that some interviewable residents in the hallway should have been included in the investigation, acknowledging that the process was not thorough and did not meet the facility's own policy requirements.