Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of abuse and neglect involving multiple residents. In one case, a moderately cognitively impaired resident residing on a memory care unit reported a possible sexual abuse incident to a family member, which was then reported to facility staff. Although the facility's investigation included interviews with the resident, family, and staff, there was no evidence that a physical assessment was conducted at the time the allegation was reported. Additionally, no interviews were conducted with other residents on the same unit, nor were assessments completed for other vulnerable residents who may have been affected. In another incident, the DON was made aware of an allegation of neglect involving a resident found in a soiled brief with sacral excoriation. The ADON took a photograph and applied a moisture barrier cream, but there was no documented skin assessment of the excoriation. Further review revealed that the GNA responsible for the resident had documented care for several other residents during the same shift, despite evidence that care was not provided, and similar documentation patterns were found over three consecutive days. The DON and NHA were unaware of the extent of inaccurate documentation and lack of care provided by the GNA. A third incident involved an allegation of physical abuse reported by a resident's family member. The facility's investigation included staff statements, but most did not specify the relevant date or shift, and statements were missing from several staff who worked during the period in question. Of the 32-33 residents on the unit, only four were interviewed, and there were no physical assessments for residents who could not be interviewed. These deficiencies in the investigative process were acknowledged by facility leadership during interviews with surveyors.