Failure to Thoroughly Investigate Alleged Abuse and Neglect Following Social Media Incident
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for four residents following a social media post that included photographs of residents in various stages of undress and allegations of inadequate care. The facility's own policies required prompt and comprehensive investigations, including interviews and written statements from staff, residents, and families who might have relevant information. However, the investigation lacked key elements such as staff witness statements regarding the social media post, interviews with all potentially involved staff, and inclusion of all affected residents, specifically omitting one resident entirely from the investigation process. The investigation primarily focused on dignity concerns rather than abuse, as indicated by the actions of the Administrator and DON. Resident interviews were limited to a standard dignity worksheet that did not address the specific issues of abuse, use of cell phones, or unauthorized photography. Some residents expressed concerns about their care, but there was no documented follow-up. Additionally, not all residents or their responsible parties were interviewed, and there was no evidence that families were informed or questioned about the incident, despite the public nature of the social media post. Staff interviews were incomplete, with only select CNAs providing written statements based on assignment sheets, and other staff who may have had relevant information were only spoken to informally without documentation. The facility leadership acknowledged that the investigation was general due to an inability to identify all residents in the photographs, and they did not consider the incident as abuse. The lack of comprehensive interviews, documentation, and inclusion of all potentially affected individuals led to an incomplete investigation, contrary to facility policy and regulatory requirements.