Failure to Implement Abuse Investigation Policies and Procedures
Penalty
Summary
Facility staff failed to implement established policies and procedures for investigating allegations of abuse, neglect, and theft involving multiple residents. In several incidents involving residents with cognitive impairments and dementia, staff did not complete or document required investigative steps. For example, after a nurse witnessed one resident strike another, the facility's documentation lacked evidence of interviews with the residents involved, staff, or other potential witnesses, and did not include a summary of the investigation or supporting documentation. Similar deficiencies were noted in subsequent incidents involving the same resident and others, where only clinical records were present in the investigation files, and final reports to the state agency were missing from the facility's records. In another case, a resident sustained significant injuries, including a laceration, bloody nose, and orbital fracture, following an altercation with a roommate. The facility's documentation included only a single witness statement from an LPN and lacked evidence of interviews with the residents involved, other staff, or a comprehensive review of medical records. The executive director confirmed that the investigative file was incomplete and did not meet the facility's own standards for a thorough investigation. Throughout these incidents, the facility's failure to follow its own abuse investigation policy was evident. Required steps such as obtaining statements from all involved parties, conducting thorough assessments, and maintaining complete investigative files were not performed or documented. Administrative staff acknowledged these deficiencies during interviews, and no additional information or corrective documentation was provided prior to the survey exit.