Failure to Conduct Thorough Abuse Investigation and Required Reporting
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving a resident with severe cognitive impairment, quadriplegia, and a history of traumatic spinal cord dysfunction. The incident involved the resident reporting that a CNA had water thrown in their face, and the CNA was suspended pending investigation. However, the facility's investigation was limited, as only the resident was interviewed, and no additional resident or staff interviews were conducted to determine if others were affected or if there was a pattern of behavior by the CNA. The facility also did not ensure that all required documentation and notifications were completed, as there was no evidence of notification to the nurse aide registry regarding the substantiated abuse allegation. Further, it was discovered that the CNA involved had not completed mandatory training within the required timeframe, and this was not addressed prior to the incident. The facility's policy required protections against abuse, neglect, and exploitation, but the investigation did not meet these standards due to incomplete interviews and lack of proper reporting. The regional administrator later acknowledged that the required notification to the nurse aide registry had not been made, indicating a gap in compliance with state reporting requirements.