Failure to Investigate and Document Abuse Allegations
Penalty
Summary
Facility staff failed to complete and document a full investigation into two separate allegations of abuse made by a resident against staff members. According to the facility's Abuse Prohibition Protocol, all alleged violations involving abuse must be reported, investigated, and documented, with accused staff suspended pending investigation. However, in both incidents, the facility did not conduct or document a comprehensive investigation, including interviews with other staff or residents, nor did they suspend the accused staff as required by policy. The resident involved had a complex medical history, including dementia, major depressive disorder with psychotic symptoms, anxiety disorder, PTSD, and physical limitations requiring extensive assistance with activities of daily living. The resident reported being abused by staff and claimed to have bruising, but assessments by the Social Services Director (SSD) and charge nurse found no bruising. Despite these allegations, there was no evidence in the records of a thorough investigation or documentation of steps taken to protect the resident during the process. Interviews with facility staff, including CNAs, CMTs, the DON, and the Administrator, revealed inconsistent knowledge and application of the abuse investigation protocol. Some staff were unaware of the allegations or the required suspension of accused staff, and the Administrator admitted to not completing or being aware of investigations for the reported incidents. The lack of a documented, comprehensive investigation and failure to follow facility policy led to the deficiency.