Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or misappropriation were thoroughly investigated for six residents. In multiple instances, the facility did not obtain written statements from all staff assigned to the relevant units during the periods of the alleged incidents. For example, after a resident reported inappropriate touching by a former roommate, the facility did not collect statements from the certified nurse aides on duty or the registered nurse involved, and the investigative summary was neither dated nor signed by the Medical Director. Similarly, in an incident where a resident was struck on the head with a therapy device by another resident, the investigative summary was unsigned and undated, and not all required staff statements were obtained. In cases involving missing property and alleged financial exploitation, the facility did not secure statements from all staff assigned to the affected units during the relevant timeframes. For three residents who reported missing credit cards and unauthorized charges, the investigation lacked comprehensive staff interviews and written statements, including from the alleged perpetrator in one case. The facility's incident reports concluded that exploitation or misappropriation by staff was inconclusive due to insufficient evidence, but the lack of thorough documentation and staff statements was evident. Throughout these events, the facility's own policy required that all allegations be thoroughly investigated, with interviews conducted with all staff members on all shifts who had contact with the residents during the periods in question. However, the documentation reviewed showed that investigative summaries were often incomplete, unsigned, or undated, and that not all relevant staff were interviewed or provided written statements. These deficiencies in the investigative process were confirmed by interviews with facility leadership, who acknowledged that some steps were missed or overlooked.