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R0304

Failure to Conduct Comprehensive Abuse Investigation

West Bloomfield, Michigan Survey Completed on 04-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident was admitted to the facility and later reported to have been sexually abused. The clinical record showed that the resident expressed confusion and reported to a nurse that she believed a man had been in her room. Subsequently, while at the hospital, the resident alleged to police that she had been raped by a male caregiver, but later denied the allegation. The facility's investigation file indicated that only the resident's responsible party and two male staff members from the unit were interviewed. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time, the nurse who documented the initial report, or other residents. The facility's abuse and neglect policy required a thorough investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. However, the investigation did not include interviews with all potentially relevant staff or residents, and the Abuse Coordinator was unaware of the initial report made by the resident to the nurse. The documentation and investigation process did not meet the facility's stated policy requirements for a careful and deliberate investigation.

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