Failure to Investigate and Protect Residents During Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of physical abuse involving three residents. Specifically, the facility did not ensure that all allegations of abuse were fully investigated or that residents were protected during the investigation process. The facility's own policy required that an investigation team review all events by the next working day, assign someone to complete the investigation, update care plans with new interventions, and interview relevant parties. However, documentation showed that these steps were not consistently followed for the incidents involving the sampled residents. In one incident, a resident sitting in a wheelchair was physically struck multiple times by another resident, and staff intervention occurred only after the altercation escalated. In another event, two residents were found swearing at each other, with one resident discovered tipped backward in his wheelchair holding his head. The facility lacked evidence of comprehensive investigations into these events and did not demonstrate that all residents were protected during the investigation period.