Failure to Thoroughly Investigate Allegations of Staff Misconduct and Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of staff misconduct and abuse involving two residents. In the first case, a resident with a history of stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea, who required significant assistance with activities of daily living, reported that a CNA was rude, removed her call light out of reach, and spilled a bedpan on her bed. The resident's son and other staff corroborated aspects of her account, including the removal of the call light and the resident being upset. However, the facility's investigation did not include interviews with other staff who cared for the resident after the incident, nor did it include a comprehensive follow-up interview with the resident. Statements from involved staff were not formally documented, and other staff who were aware of the incident were not asked to provide statements. In the second case, another resident, recently admitted for rehabilitation after a fall and with a UTI, reported that staff were mean to her and described an incident involving a male staff member, which was not corroborated by staffing records. The resident exhibited confusion, paranoia, and combative behavior, as documented in progress notes and staff interviews. Despite these concerns, the facility's investigation was limited to a conversation with the resident's family and a single staff member. There was no evidence of interviews with other residents or staff who cared for the resident after the alleged incident, nor was there a thorough follow-up interview with the resident herself. Both cases demonstrated a lack of comprehensive investigation into allegations of staff misconduct and abuse. The facility did not follow a systematic process for interviewing all relevant parties, collecting written statements, or ensuring that all aspects of the allegations were explored. Additionally, the facility was unable to provide a policy regarding the investigation of abuse allegations, and there was no evidence that a thorough or standardized investigative process was followed.