Failure to Complete Thorough Abuse Investigation
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following an allegation of physical abuse involving one resident. According to facility policy, all reports and allegations of abuse, including injuries of unknown origin, must be promptly reported, evaluated, and thoroughly investigated, with witness statements obtained and a conclusion documented. In this case, a resident alleged being hit in the mouth by a facility employee. The facility obtained statements from two nurses present at the time but did not obtain statements from the resident, other staff members present, or the alleged perpetrator. Additionally, there was no evidence in the facility documentation of a conclusion to the investigation, and no PB 22 form was filed for the alleged perpetrator as required. An interview with the Nursing Home Administrator confirmed that the investigation was not thoroughly completed and that the necessary documentation and reporting steps were not followed.