Failure to Thoroughly Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse made by a resident against the Administrator. The resident reported feeling verbally abused after being told by the Administrator that they would never get out of their wheelchair, were a failure, and would die in the facility. The resident was visibly distressed when recounting the incident, but could not recall the exact date it occurred, only that it was before a resident council meeting. The Chief Nursing Officer (CNO) initiated a state report and placed the Administrator on administrative leave, but did not accurately interview the resident to clarify the nature and timing of the allegation. Additionally, there was no documentation of the interview with the resident, and the CNO assumed the incident occurred during the council meeting without confirming this with the resident. The investigation was further compromised by the lack of documentation of an interview with the Administrator, despite the CNO stating that a conversation had occurred. The CNO also failed to contact the resident's provider regarding the abuse allegation, as required by facility policy. During the investigation, the CNO had another nurse interview five additional residents to assess for further concerns, but did not document these interviews thoroughly. Two of these residents reported feeling verbally abused by the Administrator, but their comments were not investigated further. Facility policies require immediate response and thorough investigation of abuse allegations, including contacting the resident's provider, interviewing all relevant witnesses, and documenting findings. In this case, the investigation was incomplete due to failure to clarify the allegation, lack of documentation, and failure to follow up on additional reports of abuse from other residents. As a result, the investigation did not address all potential instances of abuse and did not ensure the safety and rights of the residents involved.