Failure to Thoroughly Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of staff-to-resident abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia, encephalopathy, and Parkinson's disease. The incident occurred when two certified nurse aides were providing care and the resident became combative, resulting in one aide allegedly hitting the resident in response to being struck. The facility's investigation did not include a review of available camera footage, and the internal investigative documentation was incomplete, missing required signatures from the Administrator, the medical provider, and the nurse manager. Additionally, the facility did not provide documented evidence that law enforcement was notified regarding the alleged abuse, as required by policy. The Administrator stated that law enforcement was not contacted because the resident did not wish to press charges, and a referral to the Certified Nursing Aide Registry was not made for the staff member involved. The Director of Nursing was not involved in initiating the investigation, and the medical director, as well as the primary physician, were not notified of the incident until several days after it occurred. Facility policy required that all elements of an abuse investigation be completed within 48 hours and that completed investigations be reviewed and signed off by the Administrator, Medical Director, Director of Nursing, and Social Services. In this case, the investigation was not coordinated as per policy, and key personnel were not informed or involved in a timely manner. The lack of a nurse manager and staff educator contributed to the incomplete documentation and review process.