Failure to Implement and Document Abuse Investigation Procedures
Penalty
Summary
The facility failed to implement and follow its written policies and procedures for investigating an allegation of abuse involving one resident. After a resident stated during a council meeting that they felt verbally abused by the Administrator, the Chief Nursing Officer (CNO) initiated a state report and began an investigation. However, the CNO did not document the interview with the resident, did not interview or document an interview with the Administrator, and did not notify the resident's provider of the allegation. The CNO also had a nurse interview five other residents, but the documentation of these interviews was undated, and the CNO did not investigate further when two of these residents reported feeling verbally abused by the Administrator. The facility's policy required coordinated investigation efforts between Risk Management and Human Resources, including documentation of all steps, interviews with involved parties, and maintenance of records in the designated reporting system. The investigation was not adequately monitored by either the HR Department or Risk Management to ensure all procedural steps were completed and documented. The Clinical Risk Manager relied on verbal updates from the CNO and did not review the investigation documentation or ensure that all required steps were followed. The HR Director provided only verbal guidance and was not directly involved in the investigation or documentation process. Additionally, the facility did not have a functioning grievance committee as required by its own policy, and all grievances were being addressed in the Quality Assurance and Performance Improvement (QAPI) committee. The lack of oversight and incomplete documentation resulted in an inadequate investigation of the abuse allegation and failure to follow up on additional concerns raised by other residents. This placed all residents at risk for suboptimal investigations of complaints and grievances.