Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving four residents. In several cases, required documentation such as real-time nurse progress notes, risk management assessments, and notifications to key administrative staff were missing from the electronic health record. Investigations often lacked essential components, including timely and complete interviews with involved parties and witnesses, as well as proper documentation of the investigative process. In one instance, a staff member accused of abuse had not received post-incident training, and there was no evidence of a psychological evaluation or care plan update for the resident involved. In another case, the investigation file was incomplete and inaccurate, with missing dates and times for interviews and a lack of follow-up on staff admissions regarding the incident. The investigation did not include necessary assessments such as skin and pain evaluations for the resident, nor did it provide evidence of post-incident staff education or referral to psychological services. The facility's documentation also failed to address the resident's chronic pain and polyarthritis, which were relevant to the allegation. Additional deficiencies included delayed or absent interviews with potential witnesses, such as a roommate who was not promptly interviewed despite being cognitively intact and available. In several investigations, the rationale for not substantiating abuse was based on residents' confusion or inconsistent accounts, rather than a comprehensive review of all available evidence. These actions and omissions resulted in incomplete investigations that did not meet the facility's stated standards for responding to abuse allegations.