Incomplete Investigation of Abuse Allegation Involving Psychoactive Substance
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with multiple diagnoses, including schizophrenia, auditory hallucinations, and chronic pain syndrome. The incident involved two dietary aides who provided the resident with THC gummies on two separate occasions after the resident had jokingly requested them. The facility's investigation included interviews with the involved resident and two unidentified dietary staff, both of whom confirmed the aides' actions. Additionally, three other residents were interviewed, but they were only asked general safety questions and not specifically about the incident or drug-related concerns. The investigation substantiated the allegation, as evidenced by the termination of the two dietary aides. However, the investigative process was incomplete because resident interviews did not address the specific incident or related drug concerns, limiting the scope and thoroughness of the inquiry. This incomplete approach created the potential for undetected harm due to the lack of comprehensive investigative procedures.