Failure to Thoroughly Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident reported by a resident who stated that she woke up with someone lying next to her in bed and that her brief had been pulled down, exposing her. The facility did not identify this incident as potential abuse and did not report the allegation or the results of their internal investigation to the Office of Healthcare Assurance as required. The investigation was led by the Assistant Director of Nursing, who interviewed the resident and reviewed video surveillance, but the documentation of the investigation was incomplete and not in sequential order, with missing times and unclear formats for staff statements. Key investigative steps were omitted, including not interviewing the resident's roommate, who may have had relevant information, and not obtaining statements or interviews from three CNAs and an RN who were assigned to the unit during the period in question. The facility's policy specifically required obtaining statements from roommates when applicable, but this was not done. Additionally, the investigation notes did not include a summary of the findings from the surveillance camera review or correlate these findings with staff statements and interviews. The documentation provided by the facility lacked a clear summary and conclusion of the investigation. Several staff statements were undated or dated several days after the incident, and it was unclear whether they were written or obtained through interviews. The investigation record also did not include a comprehensive assessment of the resident by the nurse, as the lower abdomen and pelvic area were not examined. These omissions resulted in an incomplete investigation and failure to meet regulatory requirements for responding to and documenting alleged violations.