Administrator Lacked Training, Leading to Inadequate Abuse Investigation
Penalty
Summary
The facility failed to ensure that the administrator was knowledgeable about and followed the facility's abuse policy, resulting in a substandard investigation of an abuse allegation involving one resident. The facility's policy required staff to be informed about abuse prevention, intervention, detection, and reporting requirements. A quarterly MDS assessment indicated that the resident involved had intact cognition at the time of the incident. An incident form documented an allegation of physical abuse, but the investigation records provided by the administrator did not include interviews with staff or other residents regarding the alleged abuse. During interviews, the administrator confirmed that they were responsible for conducting abuse investigations but admitted to being unaware of all investigation requirements at the time, as they were new to the organization and had not received training. The administrator did not conduct interviews with staff or residents, did not suspend or otherwise restrict the accused staff member from contact with the resident during the investigation, and failed to notify the state health department and local law enforcement within the required timeframes. These omissions resulted in a deficient response to the abuse allegation.