Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for three residents during a complaint survey. In one case, an incident was reported in which three staff members allegedly held a resident down while the resident resisted. The facility's investigation included interviews with seven residents but did not include any staff interviews. In another case, a resident with a traumatic subarachnoid hemorrhage, quadriplegia, and contractures was found with facial swelling and discoloration. The investigation included interviews with other residents and three staff members from the day shift, but did not include the GNA who cared for the resident overnight or other staff from previous shifts. In the third case, a resident's visitor reported inappropriate touching. The investigation consisted only of a statement from the ADON and an interview with the resident, who reported feeling uncomfortable but denied being touched. No staff or other resident interviews were conducted for this incident. In each instance, the investigations were incomplete, lacking interviews with all relevant staff or other residents who may have had information about the alleged incidents. The Nursing Home Administrator confirmed during interviews that these investigations were not thorough and stated that she was not employed at the facility at the time the incidents occurred.