Failure to Conduct Thorough Abuse Investigation and Implement Immediate Interventions
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse and did not implement immediate interventions to prevent potential abuse while the investigation was ongoing. A resident, who was cognitively intact and dependent on staff for activities of daily living due to multiple medical conditions including a femur fracture, chronic kidney disease, diabetes with neuropathy, and morbid obesity, reported to the Administrator that certified nursing assistants (CNAs) had yelled at her. The incident was reported to the state, and the CNAs were suspended pending the investigation outcome. However, the clinical record lacked documentation of the resident's allegation and subsequent facility actions, and the abuse investigation file was incomplete, missing a statement from one of the CNAs and additional staff and resident interviews. The investigation documents provided by the facility were inconsistent and contained errors, such as undated or incorrectly dated staff interviews. There was also evidence that staff interviews were not conducted promptly, and some documentation did not accurately reflect whether abuse had been witnessed or the correct dates of the interviews. Confidential interviews revealed that one CNA had referred to the resident in derogatory terms and had used inappropriate language in the presence of other staff, with uncertainty about whether residents overheard. The resident and her representative described incidents where the resident felt intimidated and upset by staff comments regarding her incontinence, and the resident expressed fear of retaliation after reporting the incident. Despite the facility's policy requiring all allegations of abuse to be thoroughly investigated and for accused employees to be placed on leave with no resident contact until the investigation is complete, the investigation was not comprehensive. The facility failed to obtain all relevant statements, did not document all actions taken, and did not ensure immediate protective interventions were in place while the investigation was ongoing. These deficiencies were directly observed and documented by surveyors during the review of records and interviews with staff, the resident, and her representative.