Failure to Assess Nonverbal and Cognitively Impaired Residents During Abuse Investigation
Penalty
Summary
The facility failed to ensure that nonverbal and/or cognitively impaired residents were assessed during an abuse investigation. According to facility policy, the Administrator and/or Director of Nursing (DON) are required to immediately initiate a thorough internal investigation of any alleged abuse, which includes collecting evidence and interviewing alleged victims and witnesses. In this case, a resident reported physical abuse, prompting the suspension of a male staff member and interviews with staff and other residents on the same hallway. However, the investigation documentation revealed that two residents were unable to speak and one was unable to answer, and there was no evidence that these nonverbal or cognitively impaired residents were assessed as part of the investigation. During an interview, the DON confirmed that she could not verify whether nonverbal or cognitively impaired residents were assessed during the investigation. She acknowledged that she should have assessed these residents and admitted that a thorough investigation was not completed. The facility's failure to include assessments of nonverbal and cognitively impaired residents during the abuse investigation constituted a deficiency in following their own investigative protocols.