Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving four residents. In one instance, a resident with intact cognition and a history of falls reported that a registered nurse physically abused them by grabbing their head and squeezing their arm after a fall. Although staff were informed and some statements were collected, the Director of Nursing (DON) did not initiate a comprehensive investigation, did not suspend the accused nurse, and did not report the incident to the State Survey Agency as required. Witnesses were not fully interviewed, and documentation was incomplete. Another resident alleged that a housekeeper pushed them, an incident witnessed by staff. However, the facility did not perform a skin audit or trauma assessment on the resident, nor did it obtain a written statement from the resident or interview other potential witnesses. The investigation relied on a summary of staff interviews and did not include direct input from the resident or other residents in the area at the time of the incident. A third resident reported that another resident attempted to touch them inappropriately and that subsequent retaliation occurred. Despite the resident self-isolating and reporting the incident to multiple staff members, the facility did not conduct an investigation into the allegation. Additionally, an allegation of verbal abuse made by another resident was not thoroughly investigated, as the facility failed to obtain written statements from staff or residents related to the claim. These failures were contrary to the facility's own policies, which require comprehensive investigation and documentation of all abuse allegations.
Removal Plan
- Obtain statements from involved residents #41, #22 and #33
- Assess residents #41, #22, and #33 to ensure no injuries, physical or psychological, are present
- Suspend RN #20 and Housekeeper #28
- Suspend the administrator and director of nursing
- Obtain statements from the accused employees #20 and #28
- Social Services to meet with involved residents #41, #22 and #33 to address any psychosocial concerns
- Notify responsible parties of residents #41 and #33 of the allegations
- Notify police of the allegations of physical and sexual abuse
- Notify Maryland Department of Health of the allegations of physical and sexual abuse
- Notify Medical Directors of the allegations of physical and sexual abuse for residents #41 and #33
- Notify Ombudsman of the allegations of physical and verbal abuse
- Complete trauma informed evaluations for identified residents #41 and #33
- Educate all current employees regarding investigation of abuse
- Educate nurse managers and social workers on abuse investigation