Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident with diagnoses including major depressive disorder, chronic pain, anxiety disorder, and persistent mood disorders. An incident report documented an allegation that a CNA forcefully pushed the resident in their wheelchair away from the nurse station and hit the wall. The facility was unable to provide statements from either the resident or the CNA involved regarding the incident, nor could they confirm if there were any witnesses or the specific time the incident occurred. Additionally, the facility's quality assurance committee report did not show that abuse was monitored for compliance following the incident. The administrator confirmed that there was no documentation or investigation available to demonstrate that a thorough investigation had been completed, and review of QAPI committee documentation did not indicate that abuse had been identified or addressed after the incident.