Failure to Thoroughly Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of staff-to-resident abuse for two of three residents reviewed for abuse. In the first case, a resident with chronic obstructive pulmonary disease (COPD) reported that an agency CNA was rough when assisting her to bed, specifically stating that the CNA threw her legs onto the bed aggressively. The investigation into this incident did not include an interview with the resident, the alleged CNA, or any other staff or residents who may have witnessed or experienced similar care from the CNA. There was also no documentation of attempts to interview the alleged CNA. In the second case, a resident with chronic kidney disease reported that an agency staff member on the overnight shift told her to "hold it" instead of assisting her to the restroom. The investigation similarly lacked interviews with the resident, the alleged CNA, or any other staff or residents regarding the care provided by the CNA in question. The facility's policy requires thorough, well-documented, and immediate investigations, including interviews with all relevant parties, but these steps were not followed. The administrator acknowledged that the investigations were incomplete and that there was no documentation of an interview with the alleged CNA.