Failure to Investigate Alleged Abuse per Facility Policy
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident who was cognitively intact, had upper extremity impairment on one side, used a wheelchair, and had diagnoses of anemia and renal insufficiency. The resident reported that a certified nurse assistant (CNA) slammed them into the restroom and forced them to stand up despite their request for a lift, resulting in the CNA slamming the resident's leg against their foot. The facility's documentation included a grievance/complaint report and some progress notes indicating that the resident was upset and that the facility intended to start an investigation. However, there was no written statement from the resident about the alleged incident, and the documentation lacked a summary, conclusion, or findings of the investigation. Review of the facility's investigation materials revealed significant omissions. There was no completed Abuse Investigation Reporting Form, no summary of action steps taken, no documentation of notification to the Ombudsman, and no notification of investigation results to appropriate agencies. The investigation file only included a corrective action memo for the CNA, an employee written statement, and records of in-service training, but none of the in-service documentation showed that the CNA involved received the training. Additionally, there was no documentation of the CNA's suspension or reassignment, and no evidence that the required abuse investigation procedures outlined in the facility's policy were followed. Interviews with facility leadership confirmed that the incident was not investigated as abuse. The Executive Director and Acting DON determined the event was a customer service issue rather than abuse, and therefore did not follow the facility's abuse investigation policy. The Executive Director and Regional Nurse Consultant both stated that all allegations of known or suspected abuse should be fully investigated and documented, but this did not occur in this case.