Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents. In one case, a resident reported being struck by a staff member during feeding, resulting in visible redness and pain near the eye. The facility's documentation lacked timely and complete follow-up, including missing a required follow-up change in condition form and failing to ask the resident about the injury. The Director of Nursing confirmed that the necessary follow-up was not completed, and no additional information was provided to address the lack of a thorough investigation. Another incident involved a resident who was reported by a hospital emergency department to have been pushed, resulting in significant bruising and bleeding. The facility's investigation file contained incomplete and improperly identified medical records, lacked any witness or staff interviews, and did not include a review of the resident's facility medical records. The Nursing Home Administrator acknowledged the absence of a proper investigation and could not provide further evidence to support the facility's response to the allegation. Additional deficiencies were found in the investigation of an allegation of inappropriate touching and an incident where a resident with a history of stroke and hemiplegia reported rough handling by staff. In both cases, the facility's investigation documentation was incomplete, with missing or undated interview records, unclear identification of involved staff, and inconsistencies in the reporting of events. The investigations failed to identify alleged perpetrators, lacked supporting documentation such as police reports, and did not reconcile clinical findings with the reported allegations. These failures resulted in incomplete and insufficient investigations into serious allegations of abuse.