Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with schizoaffective disorder, anxiety, depression, anemia, and PTSD. The incident began when the resident, who was cognitively intact but had disorganized thinking and an ostomy, became agitated after being told she could not go outside to smoke outside of scheduled times. According to documentation, the resident threw water on an LPN, and there were conflicting accounts regarding whether the LPN retaliated by throwing water back on the resident. The resident subsequently called the police, and the LPN was later terminated for not de-escalating the situation. The facility's investigation into the incident was incomplete. The available documentation included only a few resident statements, one staff statement, and lacked comprehensive interviews with all potential witnesses. Interviews with staff and residents conducted by surveyors after the fact revealed that some staff had witnessed the LPN throw water on the resident in response, contradicting the facility's initial determination that the allegation was unsubstantiated. The Regional Director of Operations confirmed that the investigation was not thorough, and the Vice President of Operations acknowledged that required documentation was not completed or available for review. The facility's policy required a thorough investigation of all alleged violations, including interviews with the resident, accused, and all witnesses, as well as proper documentation of the investigation. In this case, the facility did not follow its own policy, as key witness interviews and statements were missing, and the investigation was not adequately documented. This failure affected one resident out of seven reviewed for abuse, in a facility with a census of 59.