Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to thoroughly investigate abuse allegations involving two residents. In the first incident, a resident alleged being struck on the face by another resident. Although both residents were separated and the alleged victim received first aid, the facility did not interview the alleged victim's roommate, who was present in the room and could have been a witness. There was no documentation explaining why this potential witness was not interviewed, and the Director of Nursing (DON) confirmed that the interview should have occurred. In the second incident, another resident was struck on the back of the neck by a peer while waiting in the patio. Although staff intervened and separated the residents, the facility did not interview other residents who were present and may have witnessed the event. The DON acknowledged that these potential witnesses were not interviewed, stating that staff relied on their own observations. In both cases, the facility's investigation documentation did not include interviews with all possible witnesses as required by policy.