Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with moderate cognitive impairment and a history of dementia, anxiety, and depression. The incident was reported after a family member was informed by the resident that someone had struck them on the head with a book, and the family member observed two small abrasions on the resident's head. The family member did not immediately report this to staff, but later relayed the information during a routine call with an LPN, who then assessed the resident but did not document any findings or complete a progress note. The facility's investigation was incomplete, as it lacked documentation of a thorough assessment of the resident following the allegation, including a skin assessment or other interventions. The investigation file contained only two witness statements, neither of which were from staff or residents who may have witnessed the event. The DON reviewed camera footage and interviewed the alleged perpetrator, another resident, but did not document interviews with other staff or residents. The facility's policy required comprehensive documentation and interviews, which were not followed in this case. Interviews with facility leadership confirmed that the expected procedures for investigating abuse allegations were not met. The DON and Administrator acknowledged that interviews and assessments were not properly documented or retained, and that the investigation did not include all necessary steps as outlined in facility policy. This failure resulted in an incomplete investigation of the abuse allegation for the resident.