Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to investigate an allegation of misappropriation of property for one resident who reported that their marijuana was stolen. The resident, who had previously expressed frustration about not being allowed to use marijuana for pain management, reported the alleged theft to nursing staff, who documented the complaint in the medical record and 24-hour report, and informed the oncoming nurse and supervisor. However, no formal investigation was conducted by administration or clinical leadership after the allegation was made. In a separate incident, the facility did not conduct a thorough investigation into an allegation that a Geriatric Nursing Assistant (GNA) threw cookies at a resident, striking them on the nose. The facility's documentation lacked statements from staff or residents regarding the alleged event, and the GNA in question was not removed from resident contact during the investigation period, despite working multiple shifts on the unit where the resident resided. The investigation relied on limited and, in one case, outdated staff statements, and did not include comprehensive interviews or evidence collection. Additionally, the facility failed to conduct a complete investigation into an allegation of abuse involving another resident with a mental health disorder and dementia. The investigation file did not contain a statement from the resident or from all potential witnesses, and although the accused GNA denied contact with the resident, there was no further inquiry into their assignment or possible interaction. The DON and Administrator acknowledged that an interview with the resident had occurred but could not provide documentation of it, and the investigation file was incomplete.