Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse involving two residents. In the first case, a resident with a history of trauma and PTSD reported that a male CNA was sexually inappropriate during incontinence care. The resident expressed discomfort with male caregivers and described feeling violated during the incident. Although the incident was reported to law enforcement, DCF, and the abuse hotline, the facility's documentation of the investigation was incomplete. There was a lack of documented staff interviews for those present during the alleged incident, and the facility did not have documentation of the roommate's statement specific to the event. Additionally, the care plan was not updated to reflect the resident's request for only female caregivers, and there was no documentation of skin assessments in the investigation file, despite claims that they were performed. In the second case, another resident with a history of trauma and psychiatric diagnoses reported that a staff member made an inappropriate personal comment regarding reproductive health. The facility's investigation documentation was insufficient, with only one undated staff witness statement provided and no documentation of interviews with other staff or residents. The facility did not complete or document skin sweeps as part of the investigation, despite indicating in their FEDREP information that such checks were conducted. The DON confirmed that weekly skin checks are expected but are not always documented in the context of abuse investigations. The facility's policy requires that statements be taken from the victim, the accused, and all possible witnesses, as well as securing physical evidence and preparing a detailed report upon completion of the investigation. However, in both cases, the facility did not follow its own policy, as evidenced by missing documentation of interviews, incomplete investigation files, and lack of thoroughness in addressing the allegations. These deficiencies were identified through interviews and record reviews conducted by surveyors.