Failure to Investigate Allegation of Verbal and Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal and mental abuse reported by a resident with moderate cognitive impairment. The resident, who was always incontinent of bowel and bladder and required substantial assistance, reported that a CNA scolded him for wetting the bed, which made him feel ashamed and afraid. The incident was reported to the Assistant Director of Nursing Services (ADNS), who interviewed the resident and notified the Administrator. However, there was no evidence that a comprehensive investigation was conducted regarding this specific allegation. Interviews with facility staff revealed that the Social Services and Admissions Liaison was not instructed to assess or interview the resident, and the Director of Nursing Services was unaware of any follow-up or investigation into the allegation. The CNA involved admitted to scolding the resident but was not questioned about this specific incident during the investigation. The Administrator confirmed that no investigation, psychosocial assessment, or counseling was provided to the resident following the report of verbal and mental abuse.