Failure to Conduct Thorough Investigation of Alleged Visitor Abuse
Penalty
Summary
The facility failed to ensure a thorough and properly documented investigation regarding an alleged visitor-to-resident altercation involving one resident. According to the facility's policy, investigations of alleged abuse must include identifying and interviewing all involved persons, including the alleged victim, perpetrator, witnesses, and others who might have knowledge of the allegation. In this case, the resident reported that a friend and former caregiver visited her, yelled at her, shook her by the arms, and may have previously taken money from her. The incident was reported to the social worker by a CNA, and the police were contacted to take the resident's statement. The facility also posted a notification to staff to prevent the friend from visiting the resident. However, the investigation did not include interviews with facility staff who may have had relevant information about the incident, nor were any other residents interviewed. The administrator stated that staff were not interviewed because the incident did not involve facility staff, and the social services director confirmed that no other residents were interviewed as there were no witnesses. The resident was assessed and found to have no physical marks and continued to participate in meals, therapy, and activities without ill effects. The lack of comprehensive staff interviews and documentation of the investigation process constituted a failure to follow the facility's abuse investigation policy.