Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure thorough investigations of multiple allegations of abuse, neglect, and exploitation involving several residents. In several instances, residents or their representatives reported concerns through the facility's grievance process, including unwanted touching by staff, rough handling during care, verbal abuse, and refusal to provide care. Despite these reports, the facility did not conduct comprehensive investigations as required by its own policies. For example, when a resident and her representative reported that an LPN touched her in a private area after she requested a female caregiver, the facility did not remove the staff member from duty pending investigation, nor did it interview other staff or residents who may have had relevant information. Similarly, when a CNA reported that an RN yelled at a resident, pulled off her blanket, and slammed doors, the RN was not suspended, and no further staff or resident interviews were conducted. The facility's policy mandates immediate action to ensure resident safety, including suspension of accused staff and thorough investigation of all allegations, regardless of perceived severity. However, in the reviewed cases, staff members accused of abuse or neglect continued to work with residents during and after the incidents. In several cases, the facility did not collect written statements from witnesses or involved parties, nor did it report the allegations to the state agency as required. Staff interviews revealed uncertainty about what constitutes a thorough investigation, and there was a lack of documentation showing that the facility followed its own procedures for investigating and reporting abuse allegations. Residents involved in these incidents had varying degrees of cognitive impairment and medical complexity, including diagnoses such as mild cognitive impairment, anxiety, depression, chronic obstructive pulmonary disease, and need for assistance with personal care. The failure to investigate allegations thoroughly was consistent across multiple cases, including those involving physical, verbal, and potential sexual abuse, as well as neglect. The facility did not provide evidence of comprehensive investigations, did not consistently remove accused staff from resident care, and did not always report allegations to the appropriate authorities, as required by policy.