Failure to Conduct Thorough Investigations of Missing Property and Abuse Allegations
Penalty
Summary
Facility staff failed to conduct thorough investigations into two separate incidents involving two residents. In the first case, a resident with mild cognitive impairment reported a missing cellphone. The facility submitted an incident report and conducted some staff interviews, but did not interview all personnel assigned to the relevant floor on the date of the incident, including housekeeping and activities staff. As a result, there was no documented evidence that a comprehensive investigation was completed regarding the missing property. In the second case, a resident with severe cognitive impairment and multiple complex medical conditions was the subject of an allegation of staff-to-resident verbal abuse. The resident's son reported overhearing a staff member use derogatory language toward his mother, but was unable to identify the specific staff member involved. The facility's investigation included interviews and written statements from staff, but the final report did not document or address two additional written statements from CNAs that alleged verbal abuse by the same staff member toward two other residents. These new allegations were not included in the final report of the original incident, despite being received before the report was submitted to the state agency. Both incidents demonstrate a lack of documented evidence that all alleged violations were thoroughly investigated as required by the facility's own policies. The failure to interview all relevant staff and to include all new findings in the final reports resulted in incomplete investigations for both the missing property and the abuse allegation.