Failure to Conduct Timely and Thorough Abuse Investigation
Penalty
Summary
The facility failed to document a timely and thorough investigation into an allegation of possible physical abuse involving one resident. The incident was reported to the Director of Nursing (DON) and the Administrator a day after it occurred, and the initial response did not include immediate notification or removal of the alleged perpetrator from resident contact. The investigation was limited to written statements from the involved CNA, two RNs, and did not include interviews with other staff or residents who may have been present or received care from the same staff member. The resident involved had a history of left-sided weakness and paralysis following a stroke, anxiety, depression, insomnia, dementia, and required substantial assistance for mobility and transfers. The resident alleged that a CNA had thrown them into bed, causing injury to their feet. The incident was initially investigated by an RN, who concluded there was no reportable occurrence and did not escalate the matter to facility leadership or suspend the CNA as required by policy. Facility policy required immediate action to protect residents and a comprehensive investigation, including interviews with all relevant staff and residents. However, documentation showed that these steps were not followed. The lack of timely reporting, failure to remove the alleged perpetrator, and incomplete investigation did not meet the facility's own abuse prevention and investigation standards.