Failure to Conduct Complete and Timely Abuse and Incident Investigations
Penalty
Summary
The facility failed to ensure complete, thorough, and timely investigations into allegations of abuse, neglect, and misappropriation of resident property for multiple residents. In several cases, investigations were incomplete, lacked necessary documentation, or did not include statements from all relevant staff and witnesses. For example, in the case of a resident with mononeuropathy and diabetes, the investigation into a missing bank card and unauthorized bank charge did not include interviews with all staff who had access to the resident, the resident’s roommate, or the resident themselves, and failed to review video evidence or obtain bank statements. The Director of Nursing Services (DNS) admitted to not performing a complete investigation due to time constraints. Another resident with anxiety and depressive disorder reported missing money, but the DNS was unaware of the incident until informed by surveyors, and the subsequent investigation lacked statements from the nurse to whom the incident was reported and other staff on the unit. In the case of a resident with legal blindness and bipolar disorder, the investigation into allegations of verbal and physical abuse by a registered nurse was incomplete, missing the resident’s statement and signatures on staff statements, and the DNS was unable to produce the full investigation documentation. Additionally, a resident with multiple fractures reported being called a racial slur by a nurse aide, but the incident was documented as a grievance rather than abuse, not reported to the State Agency, and the aide continued to work in the facility after the allegation, failing to protect the resident from further potential abuse. For a resident with obstructive hydrocephalus and vision loss who sustained an injury of unknown origin, the facility’s investigation did not include statements from all staff who worked during the relevant period, as required by policy. The DNS and Assistant Director of Nursing Services (ADNS) could not account for missing investigation statements, and there was confusion among staff regarding the storage and responsibility for these documents. Across all cases, the facility did not follow its own policies for abuse, neglect, and exploitation investigations, including immediate initiation, comprehensive documentation, and protection of residents during and after the investigation.