Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident with moderate cognitive impairment. The resident, who had diagnoses including Parkinson's disease, hypertension, dementia, and chronic pain, reported being hit by an employee at night. The incident report documented the allegation, but the resident was unable to identify or describe the alleged perpetrator. A subsequent skin assessment found no bruising or new open areas, but the resident voiced concerns about rough care during showers and believed staff had bruised her buttocks, though no bruising was observed at the time. Interviews with facility leadership revealed that the Director of Nursing (DON) and Administrator were unaware of all relevant documentation, including a progress note indicating the resident's concerns about rough care. The DON stated that the investigation was considered complete after the resident could not provide identifying information, and no staff member was suspended during the process. The Administrator also indicated that, due to the lack of identification, little action was taken, and he was not informed of all pertinent notes. The facility's abuse/neglect policy requires thorough investigation of all allegations, but the documentation and actions taken did not demonstrate a comprehensive investigation in this case.