Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and misappropriation involving three residents. In one incident, a resident with quadriplegia and moderately impaired cognition was struck in the face by another resident during a dining room altercation. The facility's investigation did not include documentation of who was present, witness statements from staff or other residents, or assessments of other residents for injury or psychosocial impact. The Administrator acknowledged that conversations with other residents were not documented and was unsure if staff were present at the time, despite facility policy requiring comprehensive interviews and written statements from all potential witnesses. In another case, a resident with multiple medical conditions, including hemiplegia and vascular dementia, was involved in the same altercation but the investigation again lacked critical details. The facility's self-reported incident documentation did not provide information about the events leading up to the altercation or any follow-up with other residents who may have been affected. The Administrator confirmed that no further investigation was conducted, as she believed the incident was straightforward, contrary to the facility's abuse policy. A third incident involved a cognitively intact resident who reported the theft of an iPad mini from her room. The investigation into the alleged misappropriation was incomplete, lacking details such as dates, times, and the content of staff interviews. The facility did not file a police report as required by policy, and the resident's daughter expressed dissatisfaction with the lack of follow-up and communication regarding the incident. The Administrator admitted that documentation of the investigation was insufficient and that required steps, such as contacting law enforcement, were not taken.