Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to identify and/or investigate allegations of staff-to-resident abuse for two residents. For the first resident, who had diagnoses including dementia, anxiety, malnutrition, and muscle weakness and was on hospice care, there were two separate reports made by a hospice social worker that the resident claimed to have been hurt by staff, resulting in bruising and wounds. These reports were communicated to both the facility Administrator and Social Service Director, but there was no evidence that any investigation was initiated or documented by the facility. The Director of Nursing confirmed that no investigation was conducted, and the Administrator could not locate any report of the allegations, acknowledging that they should have been investigated. For the second resident, who was cognitively intact and had multiple medical conditions, a family friend reported bruising, which was subsequently reported to the Administrator. While an incident report was created and some staff interviews were conducted, there was no documentation that the resident was interviewed, that other residents were questioned, or that the cause of the bruising was analyzed. Additionally, there was no evidence of staff training on reporting or investigating injuries of unknown origin, nor documentation of measures to protect the resident or prevent recurrence. The Administrator admitted to being unaware that the investigation was incomplete and agreed that all such allegations should be thoroughly investigated.