Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated for one resident. On the evening shift, a Certified Nurse Aide (CNA) reported to the supervisor that another CNA had handled a resident roughly and used foul language during care. The incident was reported at the end of the shift, after the alleged staff member had already left the building. The facility initiated an investigation the same night and suspended the accused CNA pending the outcome. However, there was no documented evidence that all staff involved were interviewed before the determination was made that the allegation was inconclusive. The facility's policy requires that all claims of abuse be thoroughly investigated, including obtaining signed and dated statements from all relevant staff and documenting reasons if any staff are not interviewed. In this case, although a log of nine witnesses was listed, not all staff were interviewed, and some interviews were conducted by phone. The Director of Nursing confirmed that not all interviews were completed, and there were no written or signed statements from staff regarding the incident. Some staff were no longer employed at the time of the investigation, further limiting the ability to gather complete information. The resident involved had diagnoses including non-Alzheimer's dementia with severely impaired cognition, hypertension, and depression. At the time of the incident, the resident was sometimes able to understand and be understood, but could not recall the incident and denied psychological harm. A skin assessment revealed no injury. The investigation concluded as inconclusive due to insufficient information, as there were no witnesses to corroborate the allegation and not all required interviews and documentation were completed as per facility policy.