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F0607
E

Failure to Protect Residents During Abuse Investigation

Mitchell, Nebraska Survey Completed on 06-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and document effective policies and procedures to prevent further abuse during the investigation of abuse allegations. A review of the facility's abuse policy revealed it did not include procedures for protecting residents while abuse allegations were being investigated, nor did it document how residents would be protected in reports to the State Agency. Additionally, an investigative summary regarding an incident involving an LPN and two residents did not contain evidence of measures taken to protect residents during the investigation. The summary only described interviews conducted by the DON and education provided to the LPN, without specifying any protective actions. Interviews with staff and administration confirmed that the alleged employee was not suspended or formally removed from duty during the investigation. The DON stated that the LPN was not suspended because they believed nothing had happened, and the NHA confirmed there was no documentation of suspension or protective measures. Staff statements and investigation documentation were either missing or only obtained after the fact, and there was no evidence that residents were protected from potential further abuse during the investigative process.

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