Failure to Thoroughly Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and injuries of unknown origin involving several residents. For one resident, grievances were filed by a roommate regarding inappropriate and rough care by a GNA, including the use of a paper towel for incontinence care and causing the resident to cry. Despite these concerns being reported to the Director of Nursing (DON), there was no evidence of a comprehensive investigation, such as a head-to-toe assessment, staff interviews, or review of other residents under the care of the involved staff. The DON acknowledged only cautioning the staff member and did not initiate further investigation after a second, separate complaint. Another resident reported being handled roughly by a GNA, but again, the facility did not conduct a thorough investigation, as there was no documentation of a physical assessment, staff or resident interviews, or statements from the staff involved. Additionally, an incident involving a resident found on the floor with a fractured tibia was not fully investigated; the facility's file lacked comprehensive staff witness statements, resident assessments, and supporting documentation. The DON confirmed that the investigation was incomplete and that relevant information was missing from both the investigation file and the resident's medical record.