Failure to Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with a history of cerebrovascular attack (CVA) and depression, who was dependent on staff for mobility and communication. According to medical records and witness statements, the resident activated the call light and waited 20 minutes before a CNA responded while on her cell phone, spoke unprofessionally, and delayed providing care. The CNA later transferred the resident roughly to a shower chair, left the resident exposed and unattended while continuing a personal phone call, and returned the resident to a dirty bed. The CNA also made inappropriate comments, including threatening language, towards the resident. The investigation into the incident was incomplete. The facility did not conduct interviews with other residents or staff who may have witnessed the alleged abuse, and the administrator was not fully informed of the abuse allegation until several days after the incident. The facility's policy required immediate investigation of all abuse allegations, but this was not followed, as confirmed by the administrator and human resources director. The lack of a thorough investigation and timely response constituted a failure to respond appropriately to the alleged violation.