Failure to Complete and Document Abuse and Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and provide clear outcomes for six residents involved in alleged abuse and physical altercations. Specifically, the 5-day investigation summaries for incidents involving alleged abuse by a CNA toward two residents, as well as physical altercations between two separate pairs of residents, did not indicate whether the facility determined if the alleged events occurred. The administrator acknowledged that the 5-day follow-up investigations were not completed according to the facility's abuse policy and procedure, and that he was unable to verify if the allegations were substantiated. Record reviews and interviews confirmed that the facility's investigation documentation lacked required findings and did not follow the established policy, which mandates thorough investigation, documentation, and reporting of all abuse allegations. The policy also requires that findings be reported to the appropriate authorities within five working days. The absence of documented outcomes for these incidents compromised the facility's ability to determine the circumstances surrounding the events.