Failure to Ensure Resident Safety and Thorough Abuse Investigations
Penalty
Summary
The facility failed to ensure resident safety and proper investigation procedures in response to allegations of staff abuse involving two residents. In the first instance, a nurse was directed to leave the facility immediately following an abuse allegation made by a resident. However, the nurse remained in the building for nearly two hours after being instructed to leave, citing the need to complete a narcotic count and hand over keys. The nurse was not escorted out, and the facility's administration acknowledged that the staff member should have been escorted to ensure resident safety. The abuse allegation was ultimately unsubstantiated, but the staff member was later terminated for insubordination. In the second instance, the facility did not conduct a thorough investigation after a resident reported to their representative that a Geriatric Nursing Assistant was rough during repositioning and turned the resident onto a side they did not want to be on. Facility documentation did not show that the specific allegation was addressed, nor did it indicate that the staff member involved was interviewed or provided a statement regarding the incident. When asked for further documentation, the facility administrator was unable to provide any additional evidence that the allegation was investigated as required.