Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving a resident with multiple medical conditions, including hypertension, pain, generalized edema, and major depressive disorder. The resident, who primarily used a wheelchair and required staff assistance for mobility and activities of daily living, was observed by multiple staff members being pushed in her wheelchair by a maintenance staff member despite her objections and requests to stop. Staff members, including a CNA and dietary staff, witnessed the incident, noted the resident's distress, and filed grievances regarding the event. However, these staff members were not individually interviewed about what they witnessed. The licensed nurse reported the incident and submitted the grievances to administrative staff, who acknowledged being informed of the situation and seeing the resident and maintenance staff together. The administrator conducted only a brief, informal interview with the resident and did not conduct a written investigation or interview the involved staff individually. No report was made to the State Agency, and no formal investigation documentation was completed, despite the facility's policy requiring immediate investigation and reporting of all alleged or suspected abuse, neglect, or exploitation.