Failure to Document Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse or mistreatment involving one of three sampled residents. According to the facility's policy, all reports of abuse, neglect, exploitation, misappropriation, mistreatment, or injuries of unknown source must be promptly reported and thoroughly investigated, including obtaining written witness statements from all staff who had contact with the resident during the period of the alleged incident. In this case, a family member reported concerns regarding a resident who was found vomiting, soiled, and receiving IV fluids without prior notification to the family. The family member also reported delays in staff response to their requests for assistance and ultimately requested the resident be sent to the emergency room. Despite these allegations, there was no documentation of written witness statements from staff members who had contact with the resident during the relevant period. The Director of Nursing (DON) stated that they had spoken with staff involved but did not document these interviews, and the Assistant Director of Nursing confirmed that they had not been instructed to conduct staff interviews. This lack of written documentation and formal witness statements constitutes a failure to follow the facility's abuse investigation policy.