Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents, both of whom had significant medical conditions and reported incidents involving staff. In the first case, a resident with diabetes, hemiplegia, anemia, and anxiety alleged that a CNA was rough during a transfer, resulting in the resident landing on the floor. The resident described the incident as not accidental and stated that the CNA was frustrated and had previously had confrontations with her. Documentation in the progress notes and initial abuse investigation report indicated that the resident complained of being hurt, but there was no detailed follow-up on what the resident meant by being hurt. Additionally, the investigation did not include interviews with other residents cared for by the accused CNA, and there was a lack of documentation regarding the resident's risk for abuse in her care plan. In the second case, another resident with chronic pain, cancer, and a fractured pelvis reported that a CNA intentionally dropped her legs onto the bed and made inappropriate comments, which the resident perceived as abusive. The resident reported the incident to the DON, who did not initiate an immediate investigation or suspend the CNA. The CNA was not asked to provide a written statement at the time, and the resident continued to be assigned to the same CNA after the allegation. The administrator was unaware of the definition of abuse and did not report the allegation to the state agency promptly, as she was still trying to identify the staff member involved. The investigation into this incident was delayed and only began after further reporting by the resident. Both cases revealed deficiencies in the facility's abuse investigation process, including incomplete documentation, lack of timely and thorough interviews, and failure to follow the facility's abuse prevention policy, which requires prompt and comprehensive investigations and interviews with other residents assigned to the accused staff. The care plans for both residents did not document their risk for abuse, and staff did not consistently follow procedures for reporting and investigating abuse allegations.