Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was thoroughly investigated for one resident. The facility's policy requires a comprehensive investigation into abuse allegations, including documentation of the date and time of the alleged occurrence, details of the incident, interviews with all pertinent parties, and collection of relevant evidence. In this case, a resident with diagnoses including schizophrenia, depression, bipolar disorder, and altered mental status, but who was cognitively intact, reported that a CNA was verbally abusive, telling her to "get my ass off the phone" while attempting to provide care. The resident stated she reported the incident to the Administrator and was told the CNA would be written up, but was not informed of the resolution. The only documentation of the incident was a grievance complaint form, which lacked key details such as the exact date of the incident. The Administrator confirmed that she spoke with the resident, the roommate, and the CNA, but there was no documented evidence of additional interviews or a thorough investigation as required by policy. The Administrator also acknowledged uncertainty about the date of the incident and that the investigation was not initiated until after the incident was reported to the State Agency. This lack of timely and complete investigation documentation constituted a failure to respond appropriately to the alleged violation.