Failure to Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident physical abuse involving a resident with severe cognitive impairment, quadriplegia, and multiple complex medical needs, including a tracheostomy and gastrostomy. The resident, who was dependent on staff for all activities of daily living and mobility, was reported by his responsible party to have alleged being hit by an unidentified male CNA. This allegation was communicated during an Interdisciplinary Team meeting, and both the Director of Nursing and the Administrator acknowledged awareness of the report. Despite the facility's policies requiring thorough and timely investigation of all abuse allegations, no investigation was initiated into the reported incident. Both the DON and the Administrator confirmed that the allegation met the criteria for physical abuse and should have been investigated, regardless of the resident's or responsible party's ability to provide specific details about the perpetrator or timing. The lack of investigation was contrary to the facility's own policies and federal requirements.