Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
Facility staff failed to thoroughly investigate multiple allegations of abuse involving several residents with cognitive impairments. In one instance, a resident with vascular dementia and a low BIMS score was witnessed striking another resident in a memory care unit. The facility's documentation included a synopsis of the event and notification of the medical doctor and responsible parties, but lacked evidence of a comprehensive investigation. There were no documented interviews with the residents involved, staff, or other potential witnesses, nor were there detailed assessments or observations beyond basic skin checks. Similar deficiencies were noted in subsequent incidents involving the same resident, including an event where the resident was seen removing his hand from around another resident's neck. In each case, the investigation files contained only clinical records and lacked required investigative documentation such as witness statements and interview notes. Another incident involved a resident with severe cognitive impairment who sustained significant injuries, including a laceration to the lip, bloody nose, and swelling to the face, after an altercation with a roommate. The facility's investigation included a synopsis of the event and a single witness statement from an LPN, but did not include interviews with the residents involved, additional staff, or other residents. The documentation failed to provide a comprehensive account of the incident or demonstrate that a thorough investigation was conducted, as required by facility policy. Interviews with administrative staff confirmed that the investigative files were incomplete and did not meet the facility's own standards for abuse investigations. The facility's policy requires statements from all involved parties and witnesses, as well as a detailed summary and supporting documentation, none of which were present in the reviewed files. The lack of thorough investigation and documentation was acknowledged by facility leadership during the survey.