Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into alleged abuse involving two residents out of a sample of 21. For one resident with moderately impaired cognition and dependent on staff for ADLs and dialysis, an allegation was made that a CNA placed a hand near the resident’s vaginal area. The incident was reported to the facility and documented, but the investigation was incomplete: local law enforcement and the facility physician were not notified, and the facility could not provide documentation of witness statements or resident interviews regarding safety. Interviews with staff revealed that some CNAs who were identified as being interviewed had not actually been interviewed or asked for statements. Additionally, the documentation related to the investigation was reportedly lost after the interim administrator resigned and the abuse manual disappeared. In a separate case, another resident with severe cognitive impairment reported being physically abused by a staff member, stating that he had informed a nurse and that the staff member was subsequently let go. However, when the administrator was asked to provide the facility’s investigation into this alleged abuse, no documentation was available. These failures to follow the facility’s abuse and neglect policy and to complete required investigative steps resulted in incomplete investigations of alleged abuse.