Failure to Investigate Alleged Abuse Reports
Penalty
Summary
The facility failed to investigate allegations of abuse for two of five residents reviewed, as required by its own policy. One resident reported to staff that two CNAs had hurt him while turning him, and also reported to the administrator that another CNA had slapped his face with a wet towel during a bed bath. The resident stated that after making these reports, the CNAs involved no longer worked with him, but no one from the facility had followed up or interviewed him about the incidents. Another resident reported that a CNA attempted to turn him alone, causing pain, and sometimes spoke to him in an unkind manner. He reported this to the DON, after which the CNA was removed from his care, but again, no investigation or follow-up interview was conducted. Interviews with the DON confirmed awareness of the complaints and that the CNAs were removed from providing care to the residents involved, but no formal investigation was initiated because the DON considered the issues to be customer service concerns rather than abuse. The DON also admitted that an investigation should have been conducted, especially after one resident was sent to the emergency room for back pain following his complaint. The facility's policy requires immediate investigation of any potential abuse or neglect, but this was not followed in these cases. Both residents involved had significant medical histories, including paraplegia and hemiplegia, and were cognitively intact at the time of the incidents.