Failure to Follow Abuse/Neglect Investigation Policy
Penalty
Summary
The facility failed to implement its Abuse Investigation and Reporting policy during an incident involving a resident who alleged neglect after a fall. According to the policy, all parties involved in an allegation are to be interviewed, and written, signed, and dated witness statements must be obtained. However, during the investigation of the incident where a resident reported being left on the floor for an hour after a fall, the facility did not obtain written witness statements from the resident or her roommate, resulting in an incomplete investigation. Facility documents submitted to the State Agency confirmed the lack of required documentation, and interviews with the Chief Nursing Officer and the resident identified specific staff members allegedly involved. The failure to follow established procedures meant that the investigation did not thoroughly identify or address the alleged perpetrators related to the neglect allegation.