Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with Parkinson's Disease, major depressive disorder, and bipolar disorder, who was assessed as having mild cognitive impairment and being able to communicate effectively. The resident reported that a staff member was rough with them in September 2024, and later alleged being hit in the face three times by a registered nurse. The initial investigation was closed without interviewing the resident, staff, other residents, family, or visitors, and without establishing a clear timeline of the event. The specific date of the alleged incident was not determined, and there was no documentation in the electronic medical record regarding the allegation. The facility's policy required that all allegations of abuse or neglect be promptly reported and thoroughly investigated, including interviews with the resident, staff, witnesses, and others who may have relevant information. However, the investigation consisted only of reviewing staffing sheets and a statement from the administrator, which concluded the allegation was unsubstantiated because the accused nurse was not scheduled to work at the time. No supporting interviews or statements were obtained, and the resident's care plan was not updated to reflect the alleged incident. Interviews with facility staff revealed that key personnel, including the DON and Activities Director, were not aware of the incident, and the administrator acknowledged that the investigation was not thorough and should have been reported to the state health department. The lack of a comprehensive investigation and failure to follow facility policy resulted in the deficiency cited by surveyors.