Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported being pushed by a housekeeper. The resident, who was cognitively intact and largely independent in self-care, reported the incident to an LPN, who assessed the resident and found no injuries. The LPN notified the nurse manager and the Administrator, and the housekeeper was removed from the immediate situation. However, the housekeeper was allowed to finish her shift and leave the facility, and there was no documentation that the housekeeper was prevented from having further contact with other residents following the allegation. The facility's investigation was incomplete, lacking interviews with other residents and staff who were present on the date of the incident. There was no documentation to determine if other residents may have been affected or if the accused staff member had additional contact with residents. The investigation report included only two staff statements and did not include statements from all relevant personnel. The Administrator acknowledged that no other residents were interviewed as part of the investigation, and only a limited number of staff were spoken to, despite directions to obtain written statements from everyone involved.