Failure to Thoroughly Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for two residents with severe cognitive impairment. In the first case, a resident with dementia and a history of behavioral issues was allegedly subjected to rough handling by a CNA during incontinence care, as reported by another CNA. The investigation did not include a physical assessment of the resident for signs of abuse, nor were other non-interviewable residents under the care of the accused CNA assessed. Only four residents were interviewed, and not all relevant staff were interviewed or provided written statements. The CNA accused of abuse was suspended but returned to work and completed required abuse training only after working several shifts without having done so. In the second case, another resident with dementia and multiple fractures was found with multiple bruises of unknown origin. The investigation included interviews with the nurse and CNAs present at the time the bruising was discovered, as well as three alert residents on the same floor. However, there was no documentation that staff who had cared for the resident in the days prior were interviewed to determine the cause of the bruising or why it had not been reported earlier. Additionally, other non-interviewable residents on the same floor were not assessed for signs of abuse or neglect. Facility policy required that all allegations of abuse or neglect, including injuries of unknown origin, be thoroughly investigated, with all pertinent information reviewed, witnesses identified, and interviews conducted with all relevant parties. The failure to assess non-interviewable residents for signs of abuse and to interview all staff involved in the care of the affected residents resulted in incomplete investigations, as confirmed by facility leadership during interviews.