Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of abuse involving a resident with visual and hearing impairments, who was cognitively intact and required supervision or touch assistance with activities of daily living. The resident reported that an unknown individual entered their room after supper, pulled down their pants, cleaned them, put a diaper on them despite not wearing diapers, and attempted to put a hospital gown on them. The resident became distressed and the individual eventually put their clothes back on. The resident informed a family member, who had video evidence of the incident and described that a CNA entered the room, attempted to change the resident, and was told by another aide that such care was not needed for this resident, who was independent. The facility's investigation was incomplete. The administrator did not collect statements from all staff present at the time of the incident, nor from other alert and oriented residents assigned to the staff member involved. The administrator also did not review the video recording provided by the family. The LPN who was present during the incident and the LPN/Infection Control Nurse who reviewed the video and performed a skin assessment were not asked to provide written statements. The CNA involved was not reached for an interview, and no documentation was provided regarding their account of the incident. Facility policy requires that all allegations of abuse be thoroughly investigated, including reviewing documentation and evidence, interviewing all relevant staff and residents, and documenting the investigation completely. The investigation conducted did not meet these requirements, as key interviews and evidence review were omitted, and the findings were not fully documented as per policy.