Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment and multiple diagnoses, including late onset Alzheimer's Disease, anxiety, and generalized muscle weakness. The resident reported to the Social Services Director (SSD) that a night aide had pushed her against the wall, and this was also mentioned to an activity aide. The facility's 5-Day Investigation included interviews with the resident, the alleged perpetrator (CNA), a CNA hall partner from the earlier shift, and the activity aide. However, the investigation did not include interviews or written statements from key staff who were present during the shift when the alleged incident occurred, specifically the CNA hall partner from the night shift, the SSD who received the report, and the LPN assigned to the resident during the relevant hours. The Nursing Home Administrator (NHA) confirmed that she did not interview any staff members who worked from 10:00 PM to 6:00 AM, despite the alleged incident occurring during that time frame. Additionally, the resident's care plan indicated a two-person assist was required for incontinence care, but it was not determined if the night shift CNA assisted or witnessed the care provided. The facility's investigation and policy did not align with the State Operations Manual, which expects interviews with all relevant witnesses and staff present during the period of the alleged incident. This incomplete investigation led to the deficiency cited in the report.