Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect for three residents. For one resident with chronic heart failure, malnutrition, depression, anxiety, and muscle weakness, an allegation of neglect was reported by a family member. The facility's investigation relied solely on medical record review and did not include statements from staff, other residents, or potential witnesses, making it unclear how abuse or neglect was ruled out. Another resident with end stage renal disease, muscle weakness, recurrent C. difficile, a sacral pressure ulcer, and anxiety disorder had two separate allegations of staff-to-resident abuse. The investigations into these incidents were incomplete, lacking documentation of staff and witness statements, and did not include monitoring for psychosocial harm or updates to the resident's care plan. The resident reported that no interventions were implemented to prevent recurrence, and staff confirmed that required documentation and care plan updates were not completed. A third resident with cerebral palsy, expressive language disorder, and cognitive communication deficit was involved in an abuse allegation reported by a roommate. The investigation did not include statements from the reporting resident, staff, or witnesses, and there was no documentation of how abuse or neglect was ruled out. Additionally, the care plan was not updated following the allegation, and staff confirmed that alert documentation and care plan interventions should have been completed but were not.