Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to provide thorough documentation and investigation of multiple allegations of abuse and misappropriation of property involving several residents. In one instance, a resident alleged physical abuse by a phlebotomist during a blood draw, but the facility's investigation did not include interviews with other residents on the unit who may have had concerns about the phlebotomist. In another case, a resident reported missing money from their purse, but the investigation lacked interviews with all relevant staff from previous shifts and included unsigned staff statements, resulting in an incomplete review. Additional deficiencies were noted in the handling of other incidents. For example, a resident alleged being hit by an LPN, but the facility could not provide any investigation documentation for review. Another resident was observed with a bruise and reported rough handling during ADL care by an agency GNA, but the investigation file was incomplete, lacking staff and resident interviews. In a separate incident, narcotic medication was reported missing, but the facility did not interview all staff who had access to the medication cart during the relevant period, and there was a delay in reporting the discrepancy to nursing administration. Further, the facility did not complete a thorough investigation into a resident's report of missing personal items and money after a hospital stay, as statements from the resident and alleged perpetrator were missing. In another case, a staff member was accused of making a threatening gesture and statement toward a resident, but the investigation did not include statements from named witnesses. In all these cases, the facility's failure to conduct comprehensive investigations and document findings contributed to the identified deficiencies.