Failure to Timely and Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of abuse and neglect for two residents. In the first case, a resident with severe cognitive impairment, hemiplegia, and dependent on staff for all activities of daily living experienced a change in condition, including shaking and lack of eye contact, which was reported by a CNA to an LPN. The LPN assessed the resident and found no immediate concerns, but the resident was later sent to the hospital for stroke symptoms. The facility's self-reported incident (SRI) investigation was not initiated until ten days after the event, and there was no documentation of staff or resident interviews related to the neglect allegation. Both CNAs involved confirmed they were not interviewed or asked to provide witness statements regarding the incident. In the second case, a resident with dementia and delusions reported to a CNA that she had been raped by a man who entered her room. The nurse was notified, an assessment was completed, and the DON was informed. The resident was sent to the hospital for examination, which yielded negative results. The SRI investigation documented that resident interviews were conducted, but there was no evidence that staff interviews or witness statements were obtained. The nurse on duty confirmed she was not interviewed about the allegation, and the administrator acknowledged the lack of documentation for staff interviews in both cases. The facility's policy requires immediate and thorough investigation of abuse, neglect, or exploitation allegations, including identifying and interviewing all relevant persons and providing complete documentation. However, in both incidents, the facility did not follow its policy, as there was a lack of timely initiation of investigations and insufficient documentation of interviews with staff and witnesses.