Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations and incidents involving three residents, as required by its own policies and state regulations. For one resident with a history of a left arm fracture and moderate cognitive impairment, an allegation of delayed call light response was reported during a resident council meeting. However, there was no documentation of the allegation in the state reporting log or the resident's health record, and the investigation lacked interviews with night shift staff, physical or psychosocial assessments, and evidence of support services provided to the resident. Another resident, who had a contusion and laceration of the cerebrum and required moderate assistance with transfers, reported waiting over 30 minutes for call light response at night and being scolded by a nursing assistant after self-transferring to the bathroom. The facility did not log this allegation, failed to document the incident in the resident's health record, and did not conduct or document interviews with relevant night shift staff or provide evidence of education or training for night shift staff. The investigation also lacked ongoing assessments, care plan revisions, and interviews with other residents or staff involved in the incident. A third resident with severe cognitive impairment and Alzheimer's was the subject of a grievance alleging inappropriate touching by a roommate. There was no investigation conducted for this allegation, and key staff were unaware of the grievance. The facility did not escalate the grievance to an abuse allegation or initiate a thorough investigation as required. These failures resulted in incomplete investigations and insufficient documentation for incidents and allegations of abuse or neglect.