Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to provide evidence of a thorough investigation into an allegation of staff-to-resident abuse involving one resident. On the date of the alleged incident, the facility's staff schedule showed that four CNAs, including the alleged perpetrator, and two RNs were present on the unit. However, the investigation packet only included information obtained from the accused CNA. There was no documentation that other staff members working at the time, the resident's roommates, or other residents on the unit were interviewed. Additionally, there was no evidence that non-interviewable residents were assessed for signs and symptoms of abuse. During an interview, the Administrator confirmed that the investigation focused solely on the resident who made the allegation and did not include interviews with other potential witnesses or assessments of other residents. This approach was inconsistent with the facility's own policy, which requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations, as well as providing complete and thorough documentation of the investigation.