Failure to Thoroughly Investigate Abuse Allegation and Protect Resident During Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with moderate cognitive impairment and a history of behavioral issues, including accusations against staff. The resident, who had restless leg syndrome, a history of falls, and impaired safety awareness, made allegations that a staff nurse physically abused him during an incident where he rolled out of bed. Despite the resident's history of making unsubstantiated claims, the facility's policy required a comprehensive investigation, including interviews with all relevant staff and residents, and removal of the alleged perpetrator from resident contact until the investigation was complete. The investigation was incomplete as staff and residents on the unit where the alleged abuse occurred were not interviewed. Only a few nurses and residents from a different unit were questioned, and key staff who had provided care to the resident were not included in the inquiry. The social worker and director of nursing acknowledged that interviews with staff and residents from the transitional care unit (TCU), where the incident allegedly took place, were not conducted. Additionally, the facility's own policy, which mandates thorough documentation and interviews with all potential witnesses and involved parties, was not followed. Furthermore, the staff member accused of abuse was allowed to return to work with resident contact before the investigation was completed, contrary to facility policy. The alleged perpetrator was suspended for only one shift and then returned to duty prior to the conclusion of the investigation. This action failed to ensure the protection of the resident and other vulnerable individuals during the investigation process, as required by both facility policy and regulatory standards.