Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of abuse and neglect for one resident. The resident, who had multiple medical conditions including a recent femur fracture, diabetes, and chronic kidney disease, reported to a mental health provider that a CNA expressed frustration about having to change him frequently due to loose stools. The resident denied physical abuse or injury but described the CNA as having an attitude and being rude. Additionally, a family member reported that the CNA or nurse was rough while cleaning the resident and slammed items down. The social worker and unit manager interviewed the resident, who did not claim abuse but complained about the CNA spraying air freshener and mumbling. No other residents cared for by the CNA were interviewed. The administrator stated that the incident was not reported to authorities because staff did not believe abuse had occurred. Instead, a grievance form was completed, and the CNA was counseled for unprofessional behavior. The facility's policy defines verbal and mental abuse, but the investigation did not include interviews with other residents or reporting to external agencies. The documentation shows that the facility did not follow its own procedures for thoroughly investigating and reporting abuse allegations.