Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an altercation between a resident and several staff members, resulting in the resident sustaining scratches on both sides of the neck and on the left hand. The initial response involved a registered nurse collecting written statements from the involved staff, but these statements were written and read aloud in front of each other, compromising the integrity of the investigation. The following day, a certified nurse aide reported to the Director of Nursing (DON) that their initial statement was inaccurate and provided a new account alleging that a staff member had assaulted the resident. Despite this new information, the DON did not further investigate the incident, did not interview the resident or other staff members privately, and did not inform the Administrator of the revised statement. The facility's own policy required immediate and thorough investigation of any allegations or suspicions of abuse, including private interviews with all involved parties and prompt reporting to the Administrator and relevant authorities. However, the investigation was limited to collecting initial written statements, with no documentation of resident interviews or private staff interviews. The DON also failed to ensure that the new allegation of staff-to-resident assault was reported or investigated according to policy. The Administrator was not made aware of the revised statement or the resident's allegations, and the incident was not reported to state agencies as required. The resident involved had a history of agitation and conflict with the staff member in question, and after the incident, was observed with visible injuries and reported feeling unsafe and distrustful of the staff. Multiple staff interviews revealed inconsistencies in their accounts, with at least one staff member stating they felt coerced into writing a false statement. The facility's failure to conduct a thorough, unbiased investigation and to follow its own abuse reporting policies resulted in a deficient practice affecting at least one resident.