Failure to Thoroughly Investigate Allegation of Exploitation
Penalty
Summary
The facility failed to provide evidence that all alleged violations related to abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a certified nursing assistant (CNA) admitted to asking a resident, who had intact cognition and diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, for $0.50 to buy a soda. The resident reported feeling compelled to give the money and subsequently informed the Administrator. The investigation conducted by the facility was limited to interviews with the resident and the CNA involved, with the CNA admitting to the request and receipt of money. There was no documentation of broader staff education or interviews, nor were other residents interviewed at the time of the incident. The facility's investigation report lacked evidence of comprehensive investigative steps, such as staff and resident interviews beyond those directly involved. The facility's policy required prompt and thorough investigation of all allegations of abuse, neglect, exploitation, or misappropriation, but the documentation did not demonstrate that these procedures were fully followed in this case.