Failure to Investigate Abuse Allegation and Provide Post-Abuse Assessments
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation and did not maintain required documentation for agency staff. Specifically, when a resident reported that another resident might have been choked by a Geriatric Nursing Assistant (GNA) from an agency, the facility was unable to provide the employee file or training records for the GNA in question. The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that they did not have the contract with the agency or any documentation of the GNA's training, and the agency was no longer in existence. This lack of documentation and inability to verify training was identified as a concern during the survey. Additionally, the facility failed to provide psychological evaluations and physician assessments for residents following a substantiated incident of resident-to-resident sexual abuse. Although the facility claimed in its investigation documentation that both residents involved had been seen by psychiatric services and the facility physician, medical record reviews revealed that neither resident had received these assessments. The DON confirmed that it was standard practice for such evaluations to occur, but acknowledged that in this case, neither resident had been seen by psychiatric services or the physician regarding the incident.