Failure to Thoroughly Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for two of four residents reviewed. In the first instance, a certified nursing assistant (CNA) reported allegations of verbal and sexual abuse involving another CNA and a resident. The report included claims of inappropriate conduct, such as flirting and the exchange of food, as well as verbal mistreatment. The facility's investigation did not include interviews with all potentially involved staff or other residents who may have had relevant information. Specifically, the second CNA on duty during the alleged incident was not interviewed, and no other residents were questioned about the allegations. The nursing home administrator acknowledged that additional interviews should have been conducted to fully understand the scope of the allegations. In the second instance, a resident with multiple diagnoses, including severe cognitive impairment, experienced a change in condition that led to hospitalization and subsequent death from sepsis. The facility initiated a self-report investigation after learning of the resident's death and diagnosis of sepsis. However, the investigation did not include interviews with staff or audits of resident care, nor was any education provided regarding the incident. The nursing home administrator confirmed that no staff interviews or house audits were completed, and there was an expectation that nursing staff would report changes in condition and complete assessments. Surveyors found, through their own interviews and record review, concerns related to the resident's change of condition, assessments, and physician notification that were not addressed in the facility's investigation. Both cases demonstrate that the facility did not follow its own policy requiring immediate and thorough investigations of alleged abuse, neglect, or mistreatment. The investigations lacked comprehensive documentation, failed to identify and interview all involved persons, and did not fully determine the extent or cause of the alleged incidents. These deficiencies were identified through observation, interview, and record review by surveyors.