Failure to Complete Timely and Thorough Investigations of Abuse Allegation and Fall Incident
Penalty
Summary
The facility failed to ensure timely and thorough investigations for two separate incidents involving two residents. For one resident, who was cognitively intact and able to communicate, an allegation was made that a staff member was verbally abusive and took a personal item (a power bank) from the resident. The resident reported the incident to another staff member but stated that no follow-up occurred and expressed ongoing distress and fear of retaliation. Investigation notes showed that while the incident was reported to the state, the facility's internal investigation was incomplete, lacking interviews with other residents, background checks on the staff involved, and updates to the resident's care plan. There was also no evidence that staff received education on reporting verbal abuse. In a separate incident, another resident with a history of heart failure and a progressive neurological disorder experienced a fall while attempting to get out of bed. The resident was found on the floor and later transferred to the hospital due to shortness of breath and inability to rise. Despite the fall, no investigation was initiated for nine days, and staff attributed the delay to an unusually high number of incidents and staff absence. The facility did not provide documentation of a completed investigation for this event.