Failure to Thoroughly Investigate and Document Abuse Allegation
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of staff-to-resident abuse and did not maintain adequate documentation. A resident reported to a nurse supervisor that a staff member made inappropriate comments during medication administration, which made the resident feel uncomfortable and embarrassed. The facility's initial response included contacting the police, suspending the alleged perpetrator, and arranging for a psychiatric nurse practitioner and social worker to meet with the resident. Statements were collected from involved parties. However, the facility's follow-up investigation relied solely on a nurse practitioner's progress note, which attributed the resident's report to attention-seeking behavior and fantasies, despite no documented history of such behaviors in the resident's medical or psychiatric records. The facility was unable to provide documentation supporting its conclusion that the incident could not be substantiated, including evidence of behavioral concerns, records of a psychological evaluation related to the incident, or verification that the social worker met with the resident as claimed. The administrator acknowledged that the decision not to substantiate the incident was based only on the nurse practitioner's note and that resident records were not reviewed. The lack of thorough investigation and supporting documentation led to the cited deficiency.