Failure to Conduct Thorough Abuse Investigations and Assess Psychosocial Impact
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents involving several residents. In each case, the staff member responsible for the investigation did not interview other residents who had received care from the accused staff, nor did they assess the psychosocial impact on the affected residents. For example, one resident reported that a staff member refused to change her soiled brief, but the investigation was limited to interviewing CNAs and did not include other residents or an assessment of the resident's emotional well-being. Another resident reported rough and abrupt care, resulting in her being tearful during the investigation, yet no further interviews or psychosocial assessments were conducted. Additional incidents included a resident who was reportedly afraid and hesitant to receive showers after an alleged rough interaction with a staff member, and another resident who felt uncomfortable and believed a staff member may have taken pictures of him during a shower. In both cases, the investigations did not extend to other residents or include any evaluation of the emotional or psychological effects on the residents involved. Documentation also showed that staff education on abuse was not provided immediately following the incidents. In another case, a resident was reportedly sprayed in the face with water by a staff member during a shower, causing distress. The investigation did not include interviews with other residents, a review of the bath schedule, or a direct interview with the accused staff member. The investigation was not updated with findings, and there was no documentation of abuse education for the staff member upon return to work. Across all incidents, the facility's own policy requiring comprehensive investigations and documentation was not followed.