Failure to Thoroughly Investigate Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was admitted with palliative care needs. The resident reported that a staff member used foul language and physically slapped her. Documentation in the resident's progress notes confirmed that the allegation was reported, and monitoring for distress was initiated. However, the investigation into the incident was limited in scope. The Social Services Director (SSD) only interviewed the resident and the alleged perpetrator, CNA 8, without interviewing other staff or residents who may have had relevant information. The SSD also did not review the employee file of CNA 8, which contained prior incidents of poor communication and inappropriate behavior. The Director of Nursing (DON) confirmed that a more comprehensive investigation should have included interviews with other staff and residents and a review of the employee's history. Facility policy required a thorough investigation, including interviews with all relevant parties and review of all events leading up to the incident, which was not followed in this case.