Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two of three sampled residents reviewed for abuse. According to the facility's Abuse Prevention Policy, any complaint or suspicion of abuse must be thoroughly reported, investigated, and documented. For one resident with multiple sclerosis, osteoporosis, contractures, and muscle wasting, an incident was reported in which the resident was left in their room with the door shut after being incontinent, causing discomfort and fear. The investigation documentation for this incident did not include statements from the resident or staff regarding the allegation, and the Director of Nursing (DON) confirmed that the incident was not thoroughly investigated. In a separate case, another resident with acute respiratory failure, seizures, spinal stenosis, and paranoid schizophrenia was the subject of an abuse allegation reported by their family, who stated that a CNA was heard speaking harshly to the resident. The investigation documentation for this incident also lacked resident and staff statements regarding the allegation. The DON reviewed the documentation and acknowledged that the incident was not thoroughly investigated.