Failure to Properly Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and protect residents following an anonymous external email alleging abuse and neglect by staff. The allegations included neglect, improper wound care, unqualified staff performing medical procedures, and direct abuse by specific staff members toward three residents with varying cognitive statuses. The facility's investigation consisted of resident and staff interviews, as well as audits of wounds, showers, insulin administration, and catheter placements, all completed within a two-hour timeframe. The investigation concluded that the allegations were unsubstantiated, with residents denying the reported events and no discrepancies found in the audits. However, the investigation did not include interviews with all employees named in the abuse complaint, nor did it document the removal or suspension of any staff during the investigation or the implementation of protections for residents. Additionally, the investigation was not conducted by a partial or non-biased party, as required by facility policy when administration is named in the allegation. The administrator, who was named in the complaint, oversaw the investigation and conducted staff interviews, despite policy requiring a separate party to investigate in such circumstances.