Failure to Conduct Thorough Investigation of Alleged Resident Mistreatment
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of staff misconduct and potential resident mistreatment. Documentation revealed that a resident, who had no cognitive impairment and required substantial assistance for toileting, reported being left on the side of her bed for two hours after being told by an aide that she would not be helped. The resident described experiencing pain as a result. Staff statements indicated that call lights were ignored for extended periods, rounds were delayed, and staff interactions with residents were at times rude and dismissive. An LPN observed aides refusing to assist residents promptly and speaking to them in a condescending manner, including an incident where a resident was denied bathroom assistance unless she agreed to use a mechanical lift, which she refused. The facility's investigative file included statements from some staff and a resident questionnaire, but lacked critical follow-up. There was no documented follow-up interview with the resident who made the abuse allegation to assess her psychosocial status after the incident. The investigative file also did not include an interview with the resident's roommate regarding the specific morning in question, nor were staff from all shifts who had contact with the resident after the alleged incident interviewed. Additionally, a key RN who was reportedly informed of the concerns was not interviewed, and attempts to contact her were unsuccessful. The facility's policy required thorough investigation of all allegations, including interviews with witnesses, the resident, staff from all shifts, and the resident's roommate, as well as complete documentation. The investigation did not meet these requirements, as several necessary interviews and follow-ups were omitted, and there was a lack of documentation regarding checks on the resident's well-being after the incident.