Failure to Prevent Abuse and Incomplete Investigations
Penalty
Summary
The facility failed to prevent potential abuse and did not complete thorough investigations or maintain proper records following documented incidents. In one case, a resident was observed by staff engaging in sexually inappropriate behavior toward a roommate, including exposing and touching private parts and inviting the roommate to participate. Despite staff awareness of these behaviors, neither the resident exhibiting the behavior nor the roommate was removed from the shared room, and no immediate protective measures were documented. Additionally, the facility did not conduct or document comprehensive investigations into allegations of misappropriation of funds and verbal abuse involving another resident. Investigation files lacked statements from the affected resident and did not include documentation or notations demonstrating that the facility reviewed relevant evidence, such as bank account transactions. When questioned, the Nursing Home Administrator was unable to provide complete investigation records or resident statements, and only a minimal, one-sentence statement was later produced. No evidence was provided to show that a statement was taken regarding the verbal abuse allegation.