Failure to Complete Thorough Abuse Investigation and Resident Monitoring
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident of staff-to-resident verbal abuse witnessed by several management staff. Although the staff member involved was immediately removed from the facility, the investigation documentation indicated that the resident was to be placed on every-shift monitoring for 72 hours and provided with one-on-one emotional support. However, review of the resident's nursing progress notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the 72 hours after the incident revealed only a single progress note two days post-incident, which described the resident as somnolent and refusing some care, with no interventions noted for these behavioral changes. There was no documentation of the required monitoring or emotional support, and the MAR and TAR did not reflect the monitoring order. Additionally, the facility did not conduct interviews or assessments with other residents to determine if there were further concerns of abuse by the same staff member, as required by facility policy. Staff interviews confirmed that no additional resident interviews were performed, and all investigation materials were limited to the file provided. The facility's policy mandates identifying and interviewing all involved persons and providing emotional support to affected residents, but these steps were not completed in this case.