Failure to Thoroughly Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, and misappropriation of resident property were thoroughly investigated for multiple residents. In several cases, when residents or their families reported abuse, missing property, or injuries, the facility's investigative reports lacked critical components such as interviews with the alleged victims, potential perpetrators, or witnesses. For example, in one instance, a resident alleged that a male CNA threw him down the hall, but the investigation did not include interviews with the resident or the staff member in question, nor did it document a skin assessment following the allegation. Similarly, another resident reported missing clothing and rings, but there was no evidence that housekeeping staff were interviewed or that a thorough search was conducted. In other cases, residents reported abuse or injury during care or transportation, but the facility's investigations were incomplete. For example, a resident alleged rough handling by a CNA resulting in a skin injury, but the investigation did not include resident interviews or skin assessments. In several incidents involving transportation accidents or injuries, the facility failed to conduct or document interviews with the residents or staff involved, and there was no conclusive documentation of the investigation's findings. Additionally, reports of missing money and jewelry were not supported by documented investigations or interviews, and the facility was unable to provide records of grievances or investigations when requested. The facility's policies required that grievances and complaints be reviewed and investigated, with written reports maintained, but the documentation provided did not demonstrate compliance with these requirements. Staff interviews revealed uncertainty about the process for investigating and documenting allegations, as well as the retention of investigation records. The lack of thorough investigations and documentation could result in violations against residents not being identified or addressed appropriately.