Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect involving three residents. For one resident with hypotension, chronic kidney disease, and nocturia, an allegation of neglect was reported to the State Agency, but the facility did not submit a comprehensive investigation. The 5-day investigation report lacked interviews with residents and staff, did not include witness statements, and failed to specify when interviews were conducted or identify witnesses. In another case, a resident with monoplegia, chronic heart failure, and depression experienced a family-to-resident verbal abuse incident. The clinical record documented the resident's depression and suicidal ideation but did not reference the incident with the family member or indicate any monitoring or visitation restrictions. The facility's investigation report was undated, did not include interviews with witnesses, the alleged perpetrator, or staff, and lacked witness statements and interview details. A third incident involved a resident with hypotension, unsteadiness, nervous system degeneration, and dementia, who was verbally abused by a staff member. The facility reported the incident but the investigation report did not include witness statements or interviews with other residents to determine if there was a trend. The staff member involved was suspended and educated, but the investigation did not meet the facility's policy requirements for thoroughness, as outlined in their abuse policy.