Failure to Document Abuse Investigation
Penalty
Summary
The facility failed to provide documentation that a proper investigation was conducted following an allegation of staff-to-resident abuse involving a resident with cerebral palsy, adult failure to thrive, cortical blindness, and epilepsy. The incident occurred when the resident's mother, who is not permitted unsupervised visits due to a history of mistreatment, observed scratches and redness on the resident's left upper arm and accused staff of abuse. The facility's policy requires prompt, comprehensive investigations with written summaries of interviews and all documentation stored in the administrator's office. However, the facility was unable to produce an investigative file or documentation related to the incident, aside from a 5-Day Follow-up report. Interviews with facility leadership revealed that the administrator and DON were aware of the incident, but neither could locate the required investigative documentation. Attempts to interview key individuals, including the resident's mother, the LPN involved, and the resident's caseworker, were unsuccessful. The DON confirmed that law enforcement was notified and the case was closed as unfounded, but no documentation of the facility's internal investigation could be provided, as required by policy.