Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence of thorough investigations into allegations of abuse and neglect for two residents. For one resident, who was cognitively intact and able to communicate clearly, an allegation of sexual abuse was reported involving a wound nurse. The resident described inappropriate touching during wound care and stated that her requests for the nurse to stop were ignored until she physically intervened. The facility's documentation showed that while the incident was reported to authorities and other residents were interviewed, there was no evidence that staff, including the alleged perpetrator, were interviewed as part of the internal investigation. Both the Director of Nursing and the Vice President of Operations confirmed that no interview with the alleged perpetrator was conducted or documented. In the second case, a resident with severe cognitive impairment and a primary language of Spanish experienced a fall during personal care. The care plan indicated the need for communication support and a low bed position as a fall prevention intervention. Documentation revealed that the resident fell out of bed while being assisted by a CNA, resulting in an abrasion. The nurse's note attributed the fall to noncompliance, but there was no clear evidence that language barriers or the resident's understanding were considered. The post-fall investigation lacked sufficient detail to determine the cause of the fall, and it was unclear if the care plan interventions were followed at the time of the incident. Interviews with staff indicated a lack of awareness of the resident's care plan interventions and insufficient investigation into the circumstances of the fall. The Director of Nursing acknowledged that the documentation did not adequately explain what happened and that more thorough questioning should have occurred. The facility's policies required comprehensive investigations and adherence to care plan interventions, but these were not fully implemented in either case.