Failure to Conduct Thorough Abuse Investigation and Maintain Staff Suspension
Penalty
Summary
The facility failed to conduct a thorough investigation and take appropriate corrective action following an incident involving a resident. According to the facility's own policies and federal guidelines, a comprehensive investigation should include systematic evidence collection, interviews with all potential witnesses, and documentation of the process. In this case, the investigation summary report showed that only the involved caregivers and other residents were interviewed, with no documentation that other potential caregiver witnesses were interviewed. The Director of Nursing confirmed that their process included interviewing only those assigned to the resident or any direct witnesses, and referenced the Purple Book for guidance. However, the investigation did not reflect interviews with an expanded sample of witnesses as required. Additionally, the staff member implicated in the incident was suspended pending investigation, but time card records revealed that this staff member worked several shifts in the facility before the investigation was completed. The Director of Nursing acknowledged that the staff member worked during the data collection phase and prior to the conclusion of the investigation, contrary to the stated protocol that suspended staff should remain out of the facility until the investigation is finished. These actions and omissions resulted in a failure to meet regulatory requirements for abuse investigations.