Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was admitted with a history of blindness in one eye and intact cognition. The resident's emergency contact reported that someone had entered the resident's room and exposed themselves. During the facility's investigation, the resident denied the allegation of exposure but reported that an unknown individual had made an inappropriate comment about the resident's breasts from the doorway before leaving. The police interviewed the resident, who again denied any exposure but confirmed the inappropriate comment. Law enforcement declined to investigate further and advised the facility to follow its own protocol. The facility's investigation included interviews with the resident and staff assigned to the area, but no witnesses were identified. A handwritten statement from an RN indicated that a resident had previously reported that four men entered the room and mentioned the word 'breast.' However, the facility did not conduct interviews with other residents on the same unit to determine if similar incidents had occurred, despite facility policy and statements from the ADON and DON indicating that such interviews should be part of the investigative process. This incomplete investigation led to the deficiency cited in the report.