Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving Resident #131, who had diagnoses including seizures and other specified brain disorders and was noted to have intact cognition and no behaviors. Upon review of a self-reported incident, it was found that while a questionnaire indicated the resident felt mistreated, there was no documentation of follow-up questions to clarify the nature, timing, or circumstances of the alleged mistreatment. The Director of Nursing confirmed that although a skin check was performed with no findings, no further inquiry was made to determine details of the alleged mistreatment. Facility policy required that residents on the same unit and the resident making the allegation be interviewed, but this was not fully carried out.