Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with diagnoses including cerebral palsy, hypothyroidism, and cerebrovascular disease, who was cognitively intact at the time of the incident. The resident reported to a case manager that a staff member had placed a sock in her mouth. Upon being notified, the Administrator spoke with the resident, who initially denied that the staff member physically placed the sock in her mouth, but later changed her account to confirm the physical act. Despite the facility's policy requiring a comprehensive investigation, including interviews with all relevant staff and residents, formal written statements, assessment for injury by nursing, and a trauma-informed care assessment by Social Services, these steps were not completed. The Administrator only spoke with the resident and the two staff members involved, without obtaining formal statements or conducting broader interviews. No assessment for injury or trauma was performed, and Social Services was not involved in the investigation process. The Administrator acknowledged that the investigation was lacking and did not follow the facility's established procedures for abuse allegations. The failure to conduct a thorough investigation and to document appropriate actions as outlined in the facility's policy resulted in a deficiency related to the facility's response to an alleged violation of resident rights.