Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse during a behavioral emergency involving a cognitively intact resident. Two staff members reported that the Human Resource (HR) Manager was abusive toward the resident during the incident, which occurred in the facility's smoke room. The facility's policy requires a comprehensive investigation, including obtaining statements from all involved staff and reviewing all pertinent information, but these steps were not fully completed. Video footage from the smoke room was provided but was incomplete, with several minutes missing at critical points during the incident. The footage that was available showed the HR Manager physically restraining the resident in an aggressive manner and staff restraining the resident in a chair. Despite the presence of multiple staff members during the incident, the facility did not obtain written statements from all witnesses, specifically failing to collect statements from a Certified Medication Technician and a Nurse Aide who were present. Interviews with these staff members later revealed that they witnessed and described aggressive and abusive behavior by the HR Manager, including physical restraint, yelling, cursing, and threatening gestures toward the resident. However, these accounts were not included in the facility's investigation, as the staff were not asked to provide statements. The administrator also did not review the available camera footage and based the conclusion of the investigation on limited information, ultimately deciding to unsubstantiated the abuse claim.