Failure to Thoroughly Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with dementia, major depressive disorder, anxiety, hemiplegia, and hemiparesis. The incident occurred during a dispute over cigarettes between a housekeeper and the resident, where the housekeeper became verbally aggressive, raised her voice, and made threatening remarks. The resident became visibly upset, cried, and expressed a desire to retaliate, indicating significant emotional distress. The facility's investigation into the incident was incomplete. While the housekeeper was suspended and some interviews were conducted, the investigation did not include interviews with all residents who witnessed the event. Specifically, two other residents who were present during the altercation were not interviewed by the administrator, and the safe surveys conducted did not address the issue of verbal abuse by staff. Additionally, the reporting of the incident was delayed, as the initial witness did not immediately report the event to the administrator as required by facility policy. Documentation and interviews revealed inconsistencies and gaps in the investigation process. The administrator assumed that the social worker had interviewed all relevant residents, but this was not the case. The social worker was unsure if interviews with all witnesses were documented, and one resident confirmed he was not interviewed about the incident. The facility's own policy requires thorough investigation of abuse allegations, but this was not followed, resulting in a lack of evidence that the incident was fully investigated to prevent further abuse.