Failure to Thoroughly Investigate Abuse Allegation per Facility Policy
Penalty
Summary
The facility failed to provide evidence that allegations of abuse were thoroughly investigated according to its own policy for one resident out of a sample of eight. The resident in question had paraplegia and moderate cognitive impairment, but was able to make himself/herself understood and had no history of hallucinations, delusions, or behavioral issues. The resident reported discomfort with a CNA, describing incidents where the CNA stroked the resident's hair and was seen handling women's underwear in a manner that made the resident uncomfortable. When the allegation was reported, the administrator initiated some steps, such as contacting the police and the resident's next of kin, and collecting statements from several staff members. However, the investigation did not include a written, signed statement from the resident or the accused CNA, nor documentation of the resident's refusal to provide a statement. The accused CNA was not contacted by the facility regarding the allegation. Additionally, there was no documentation of interviews conducted or attempted with the resident or other residents, and no summary of the investigation or corrective actions taken was included in the records. Interviews with staff revealed confusion and lack of clarity regarding the investigation process. Several staff members, including the DON and nursing staff, indicated they had not initiated or participated in an investigation into the abuse allegation. The DON, who was responsible for Human Resources duties, did not recall being informed of the allegation in a timely manner and did not conduct interviews with the resident or other residents. The administrator did not review available camera footage related to the incident. The facility's documentation did not meet the requirements outlined in its own abuse investigation policy.