Failure to Conduct Timely and Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an allegation of possible physical abuse involving a resident with severe cognitive impairment and behavioral symptoms related to dementia. The incident occurred when two nurse aides entered the resident's room to provide care, and the resident began hitting one of the aides. In response, the aide allegedly slapped the resident. The incident was not reported immediately; instead, it was reported the following day by the other aide present during the event. Upon review, it was found that the facility's investigation was insufficient. The investigation relied solely on written statements from the two nurse aides involved and did not include interviews with other staff or residents who might have had relevant information. The facility's own policy requires a comprehensive investigation, including interviews with multiple staff and residents, but this was not followed. Additionally, the investigation summary was undated and lacked documentation of immediate protective measures for all residents during the investigation period. The resident involved had a history of severe cognitive impairment, required assistance with activities of daily living, and exhibited behavioral symptoms such as physical aggression toward staff. Despite these vulnerabilities, the facility did not document a full assessment or protective interventions immediately following the allegation. The failure to follow established abuse prevention and investigation protocols resulted in a deficiency related to the facility's response to alleged abuse.