Failure to Thoroughly Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for seven residents out of thirteen facility-reported incidents reviewed during a complaint survey. In several cases, such as when a resident was found with bruising of unknown origin and another resident alleged physical abuse by a staff member, there was either no formal investigation conducted or the investigation documentation was incomplete or missing. In one instance, the Director of Nursing confirmed that an injury of unknown origin was not formally investigated and no documentation could be provided to the surveyor. Other incidents included allegations of staff physically mistreating residents, such as smacking, poking, or throwing water, as well as reports of residents not feeling safe due to staff actions. In these cases, the facility's investigation packets were either void of any investigation, lacked interviews with all relevant staff and residents, or failed to assess cognitively impaired residents who may have been affected. The Director of Nursing acknowledged that investigations were incomplete or not conducted, and in some cases, stated she was not employed at the facility during the time of the incidents. Additionally, there were incidents involving residents with severe cognitive impairment, including one where a resident was found in a compromising situation with another resident, and law enforcement was contacted. However, the documentation lacked details such as staff interviews, case numbers, or confirmation of when the incident was reported to the appropriate authorities. Across all reviewed incidents, the facility did not consistently follow through with comprehensive investigations or maintain adequate documentation as required.