Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents out of four reviewed. One resident with Huntington’s Disease and moderate cognitive impairment reported that a staff member was rude to her, and also reported a verbal altercation with a roommate that made her feel unsafe. Documentation showed that the facility moved the roommate temporarily and provided verbal education to staff, but there was no evidence of a thorough investigation or interviews with the resident regarding the acceptability of the solutions. The facility administrator, who also served as the abuse coordinator, determined these incidents did not meet the criteria for abuse and did not report them to state agencies, nor did she maintain comprehensive investigation files beyond brief notes indicating no harm or distress. Another resident reported waiting two hours for assistance, after which a staff member allegedly acted disgusted, turned her roughly, and told her to stop yelling despite her pain. The concern was documented, and a nursing assessment was performed, but there was no documentation of a thorough investigation, interviews with the resident about the acceptability of the solution, or interviews with other staff or residents. The administrator concluded the incident was related to the resident’s pain and did not identify it as an abuse allegation, documenting only a brief summary on a non-reportable allegation form. In both cases, the facility did not conduct comprehensive investigations into the allegations of abuse or mistreatment, did not interview all relevant parties, and did not maintain adequate documentation of their investigative process. The administrator relied on her own judgment to determine that the incidents did not constitute abuse, resulting in a lack of proper reporting and investigation as required.