Failure to Thoroughly Investigate Alleged Verbal and Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of verbal and mental abuse involving a resident with multiple chronic conditions, including Multiple Sclerosis, Fibromyalgia, and bipolar disorder, who was alert, oriented, and able to make autonomous choices. Two separate incidents were reported in which a staff member allegedly used derogatory language toward the resident. The facility's policy requires a comprehensive investigation, including interviews with all relevant witnesses and staff, but this was not completed as required. The Director of Nursing (DON) acknowledged knowing the identities of both the alleged perpetrator and the supervisor involved in disciplining the staff member, yet failed to include their witness statements in the investigation. Additionally, the investigation was deemed unsubstantiated primarily because the accused staff member had resigned and no other staff or residents reported hearing the incident. The omission of key witness statements and incomplete documentation led to the deficiency in the facility's response to the alleged abuse.